'-%* 



'*ll}#-. 

^ 




Book__E3 

GpightN" 



CQEaaGur osposm 






Lea's Series 
of Pocket Text-Books. 



Diseases of the Eye, Ear 
Nose and Throat. 

ByW. ly. Ballknger.M.D ,L,ecturer 
on Rhinology and Laryngology, and 
A. G.WippERN, M.D., Clinical Instruc- 
tor in Diseases of the Nose and Throat, 
College of Physicians and Surgeons, 
Chicago. 

Anatomy. 

By Frederick J. Brockway, M.D., 
Assistant Demonstrator of Anatomy, 
College of Physicians and Surgeons, 
New York. 



Bacteriology and Hygiene. 

By W. E. Coaxes, Jr., M.D., Instruc- 
tor in Bacteriology and Pathology, 
College of Physicians and Surgeons, 
Chicago. 

Diagnosis. 

By C. P. Collins, M. D., Attending 
Physician to St. L,uke's Hospital, New 
York. 

Physiology. 

By H. D. Collins, M. D., Assistant 
Demonstrator of Anatomy, and W. H. 
Rockwell, Jr., A. B , M. D., Assistant 
Demonstrator of Anatomy, College of 
Physicians and Surgeons, New York. 



Gynecology. 

By Montgomery A. Crockett, 
A. B., M. D., Adjunct Professor of Ob- 
stetrics and Clinical Gynecology. Med- 
ical Department, University of Buffalo, 
New York. 

Obstetrics. 

By David J. Evans, M. D., Demon- 
strator of Obstetrics, McGill Univer- 
sity, Faculty of Medicine, Montreal. 

Surgery. 

ByBERNB. Gallaudet,M.D., Dem- 
onstrator of Anatomy, and Clinical 
Lecturer on Surgery, College of Physi- 
cians and Surgeons, New York. 



Dermatology. 

By Joseph Grindon, M. D., Pro- 
fessor of Dermatology, St Louis and 
Missouri Medical College, St. Louis. 

Genito-Urinary and Venereal 
Diseases. 

By Sylvan H. Likes, M.D., Demon- 
strator of Pathology and Genito-Uri- 
nary Surgery at the College of Physi- 
cians and Surgeons, Baltimore. 

Chemistry and Physics. 

By Walton Martin, M. D., Assist- 
ant Demonstrator of Anatomy, and 
William H. Rockwell, Jr., A. B., 
M. D., Assistant Demonstrator of 
Anatomy, College of Physicians and 
Surgeons, New York. 

Practice of Medicine. 

By George E. Malsbary, M. D., 
Assistant to the Chair of Theory and 
Practice of Medicine, Medical College 
of Ohio, Cincinnati. 

Histology and Pathology. 

By John B. Nichols, M. D., Assist- 
ant in Pathology, Medical Depart- 
ment, University of Georgetown, and 
F. P. Vale, M. D., Demonstrator of 
Normal Histology, Medical Depart- 
ment, Columbian University, Wash- 
ington, D. C. 

Nervous and Mental Diseases. 

By Charles S. Potts, M. D., In- 
structor in Electro- Therapeutics and 
Nervous Diseases in the University of 
Pennsylvania, Philadelphia. 

Materia Medica. 

By William Schleif, Ph. G., M.D. , 
Instructor in Pharmacy in the Uni- 
versity of Pennsylvania, Philadelphia. 
Cloth, $1.50, net. 

Diseases of Children. 

By George M. Tuttle, M.D., At- 
tending Physician to St. Luke's Hos- 
pital Martha Parsons' Hospital for 
Children and Bethesda Foundling 
Asylum, St. Louis, Mo. 



tea's Series of Pocket Text-^ooks. 

3ft - 

\ 

OBSTETRICS. 






A MANUAL FOR STUDENTS AND PRACTITIONERS. 



BY / 

DAYID JAMES EVANS, M.D., 

Ledum- on Obstetrics and Diseases of Infancy, McOill University, Montreal, Canada; 
Fellow of the Obstetrical Society, London, England. 



SERIES EDITED BY 

BERN B. GALLAUDET, M.D., 

Demonstrator of Anatomy and Instructor in Surgery, College of Physicians and Surgeons, 
Columbia University, Xeiv York ; Visiting Surgeon, Bellevue Hospitcd, New York. 



ILLUSTRATED WITH ONE HUNDRED AND FORTY-NINE 
ENGRAVINGS. 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK. 



71414 



^Libr^i S of Conav^ss 

I '\fct liinu HtCHvED 

I NOV 6 1900 

ICopynghl entry 



StCVND COPY. 

Ol-tiv^rfld to 






Entered according to Act of Congress, in the j'ear 1900, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



WESTCOTT & THOMSON, 
ELECTROTYPERS, PHILADA. 



PREFACE 



The aim of the author in writing this " pocket text-book '' 
has been to supply a short, concentrated treatise on the science 
and art of obstetrics, a work that the student and junior 
practitioner may find of use in attendance on lectures or in 
every-day practice. 

The physiology of pregnancy, of labor, and of the puer- 
perium has been dealt with rather fully, before the considera- 
tion of their pathology. 

Normal labor and the more frequent difficulties have been 
dwelt on at some length, while the rarer conditions and more 
complicated operations have been described more in outline. 

In order to condense the work as far as possible the con- 
sideration of the physiology and pathology of the newborn 
has been dispensed with, these subjects being discussed fully 
in the volume on " Pediatrics " belonging to this series. 

To increase the practical usefulness of the book, a special 
effort has been made to combine conciseness with clearness, 
and to keep it within a convenient number of pages. 

The standard works on obstetrics have been largely drawn 
from, particularly those of Jewett, Hirst, Playfair, etc. 

The author takes this opportunity to acknowledge his 
indebtedness to Dr. F. Morley Fry for his advice and assist- 
ance in correcting proof, and to Dr. B. B. Gallaudet for his 
painstaking work in editing the book. 

Montreal, Canada. 



CONTENTS. 



MENSTRUATION. 



Definition; cause; structural changes; onset; character; duration; 

menopause 17, 18 

Ovulation : Graafian follicle ; ovum ; maturation of ovum ; corpus 

luteum ; ovulation and menstruation 18-21 

PREGNANCY (Normal). 

Embryology: Impregnation and conception; semen; fertilization , 

of the ovum ; development of the decidua ; reflexa ; vera ; 
layers of decidua; decidual cells; changes in the ovum ; de- 
velopment of the foetus ; segmentation ; blastodermic vesicle ; 
cleavage ; development of the membranes ; amnion ; yolk-sac ; 
allantois ; urachus ; umbilical cord ; chorion ; development of 
the placenta; structure; villi; capillaries; placenta and mem- 
branes at term ; functions of placenta ; ovum at different periods 
of pregnancy; foetal circulation 21-38 

Changes in Maternal Organism : Uterus ; increase in size ; 
changes in shape and structure ; relation to pelvis and abdomen ; 
alterations in cervix, vagina, and vulva ; changes in breasts ; 
alterations in other than the generative organs ; linese albicantes 38-44 

Duration of Pregnancy : Date of fruitful coitus ; rule for deter- 
mining ; height of fundus uteri ; date of quickening . . . . . 44, 45 

DiACiNOSTS OF Pregnancy : First trimester : suppression of men- 
struation ; nausea and vomiting ; mammary changes ; vesical 
irritation ; nervous disorders ; softening of cervix ; violet dis- 
coloration of vagina ; softening and enlargement of body of 
uterus; second trimester: foetal movement; uterine souffle; 
foetal heart-sounds ; pigmentation ; ballottement ; third tri- 
mester: pressure-symptoms; varices; disturbances of respiration 
and digestion ; foetal movements; strise; settling; summary of 

5 



6 CONTENTS. 

PAGE 

diagnosis ; differential diagnosis of pregnancy ; diagnosis of 
parity or nulliparity ; diagnosis of life or death of child . . . 45-54 
Hygiene and Managemp:nt of Pregnancy : Diet ; exercise ; 
clothing ; bathing ; care of breasts ; care of other organs and 
functions ; examination 54-56 

OBSTETRIC ANATOMY. 

Anatomical Elements in Labor 56,57 

The Uterus : Walls ; muscle-fibres ; uterine segments ; ligaments ; 

peritoneum ; relation of full-term uterus to contiguous structures 57-61 

The Pelvi-genital Canal : Bony pelvis : general description ; 
joints ; mobility of pelvic joints ; false and true pelvis ; inlet ; 
superior strait ; inferior strait ; outlet ; cavity of pelvis ; lat- 
eral grooves; planes of pelvis ; pelvic diameters; conjugate; 
transverse; oblique; measurements; inclination of the pelvis; 
soft parts of the pelvic canal : muscles ; rectum ; pelvic floor ; 
segments of floor ; fascia ; perineum ; parturient axis ; other 
axes 61-76 

The Foetus : Mature foetus ; the head : vault ; base ; sutures ; 
fontanelles; obstetric landmarks ; diameters of foetal head ; cir- 
cumferences of planes of foetal head ; moulding of head ; im- 
portance of flexion of head ; foetal trunk : diameters ; mobility 
of head and trunk ; posture of foetus ; presentations ; cephalic, 
pelvic, somatic ; positions ; vertex, face, breech, shoulder ; 
centre of gravity of foetus ; foetal movements 76-96 

MECHANISM AND COURSE OP NORMAL LABOR. 

General Definitions and Etiology: Eutocia ; uncomplicated 
vertex presentations ; primigravida ; primipara ; multipara ; 
stages of labor; duration of normal labor ; causes of the onset 
of labor ; forces of labor ; uterine contractions ; pains ; retrac- 
tion ; polarity; contraction of abdominal muscles and dia- 
phragm; gravity 96-102 

Labor — First Stage : Premonitory signs and symptoms ; charac- 
teristic signs and symptoms of the onset of labor ; mechanism 
of the first stage ; dilatation of cervix ; hydrostatic pressure of 
the bag of waters ; action of longitudinal fibres of uterus ; rupt- 
ure of membranes ; presenting part of foetus as dilator ; dry 
labors; os uteri; initial labor-pains; reflex vomiting; anatomy 
of soft parts 102-107 



CONTENTS. 7 

PAGE 

Labor — Second Stage : Mechanism ; head movement ; descent ; 
flexion ; internal rotation ; extension ; restitution or external 
rotation; delivery of the trunk; pains; sufferings of woman; 
after the birth of the child ; moulding of the foetal head ; 
caput succedaneum ; anatomy 107-116 

Labor — Third Stage: Separation of placenta; separation of 
membranes ; expulsion of placenta and membranes ; retro- 
placental hemorrhage ; completion of labor ; blood lost in 
labor 116-118 

MANAGEMENT OF NORMAL LABOR. 

Obstetric Antisepsis: Antiseptic agents; chemical antiseptics; 

the obstetrician ; methods of sterilizing hands ; the nurse ; 

the patient 119-123 

Preparations for Labor : On the part of the physician ; 

obstetric bag and contents; labor-room; linen ; vulvar pads; 

binders ; labor-bed ; aneesthetics in labor 124-127 

Management of the First Stage: Preliminary conduct of 

the physician ; obstetric examination ; palpation ; auscultation ; 

vaginal examination ; succeeding the examination ; rupture 

of membranes 128-136 

Management of the Second Stage: Position; in rapid cases; 

ansestliesia; perineal stage; laceration of perineum; at 

moment of delivery ; delivery of head ; delivery of shoulders ; 

immediate care of child; the cord 137-140 

Management of the Third Stage : To insure firm uterine 

contraction ; lacerations ; expulsion of placenta ; Crete's 

method of expression; retraction of uterus; final measures .141, 142 

THE PUERPERAL STATE. 

Anatomy of the Parts immediately after Labor : The 
uterus; vagina; vulva; bladder; peritoneum; abdominal 
walls 143-145 

Physiology of the Puerperal Period : Livolution ; circula- 
tory system ; urinary system ; skin ; digestive apparatus ; 
lactation; mammary glands; colostrum; milk 145-150 

Management of the Puerperium: Lying-in room ; genitalia; 
care of breasts ; nursing ; nipples ; contraindications to suck- 
ling ; after-pains; visits of the physician; infant's tempera- 
ture 150-154 



CONTENTS. 
PATHOLOGY OF PREGNANCY. 

PAGE 

The Dkcidua : Acute and chronic decidual endometritis; atrophy 154-156 

The Fcetal Appenda(;es: Oligohydramnios; hydramnios ; 
amniotic bands; premature rupture of amnion; alterations in 
character of liquor amnii ; vesicular mole ; anomalies of pla- 
centa ; diseases of placenta ; placental apoplexy ; placentitis ; 
tumors and oedema of placenta ; abnormal length of cord ; 
coils and knots of cord ; hernia into cord 156-165 

The Fgetus : Teratology ; foetal mortality ; elephantiasis ; ana- 
sarca ; ichthyosis ; rachitis ; syphilis ; tuberculosis ; contagious 
diseases ; foetal death 165-169 

Pathology of the Pregnant Woman: Varices; oedema; 
pruritus ; leucorrhoea ; vegetations ; retroversion and prolapse 
of uterus ; endocervicitis ; tumors ; mammary abscess ; exces- 
sive secretion of milk; eczema of the nipples; gingivitis; 
dental caries ; parotitis; ptyalism ; indigestion; constipation; 
diarrhoea ; vomiting ; pernicious vomiting ; uterus ; hemor- 
rhoids ; irritability of the bladder ; haematuria ; albuminuria ; 
kidney of pregnancy ; acute and chronic nephritis; cough; 
dyspnoea; pneumonia; phtliisis ; cardiac disease; heart-mur- 
murs ; enlargement of thyroid gland ; neuralgia ; neuroses ; 
infectious diseases 169-188 

Toxemia — Eclampsia: Symptoms; definition; frequency; pre- 
monitory symptoms ; the fit ; etiology ; pathological anatomy ; 
treatment 188-194 

Abortion and Premature Labor : Definition ; symptoms ; 
pathology ; etiology ; diagnosis ; treatment ; missed abor- 
tion ; miscarriage ; missed labor 194-201 

Ectopic Gestation : Definition ; frequency ; varieties ; tubal 
pregnancies ; terminations ; tubal abortion ; etiology ; path- 
ology ; symptoms ; treatment ; removal of sac ; technique of 
operation 202-209 



PATHOLOGY OP LABOR. 

Dystocia due to Malpositions of the Fgetus: Occipito- 
posterior cases ; face presentations ; brow presentations ; breech 
presentations ; arrest of breech at the brim ; rapid extraction 
of trunk ; delivery of the after-coming head; transverse pres- 
entations ; prolapse of the foetal limbs ; plural births .... 209-248 



CONTENTS. 9 

PAGE 

Dystocia due to Anomalies of Fostal Development : Over- 
growth of foetus ; premature ossification of skull ; hydrocepha- 
lus ; encephalocele ; meningocele ; hydrencephalus ; tumors of 
trunk ; anencephalus ; double monsters . 248-253 

Dystocia due to Abnormalities of the Fgetal Appendages : 
Short cord ; prolapse of cord ; coiling of cord about foetal neck ; 
placenta prievia ; accidental hemorrhage ; premature separa- 
tion of a normally situated placenta ; retained placenta ; ad- 
herent placenta 253-268 

Maternal Dystocia: Precipitate labor ; delayed labor; uterine 
inertia ; anomalies of the pelvis ; pelvimetry ; anomalies of 
uterine development; atresia and rigidity of cervix ; impaction 
of anterior lip of cervix ; displacements of the uterus ; pro- 
lapse ; abnormal conditions of vagina, vulva, and bladder; 
tumors of genital canal and neighboring organs ; rupture of 
uterus ; inversion of the uterus 268-312 

PATHOLOGY OF THE PUERPERAL PERIOD. 

Hemorrhages during the Puerperium: Post-partum hemor- 
rhage; secondary hemorrhage ; hsematoma 312-318 

Subinvolution: Etiology; diagnosis; treatment 318-320 

Anomalies and Diskases of the Nipples and Breasts : 
Supernumerary nipples ; inversion of the nipple ; absence of 
mammae; hypertrophy of mammae ; supernumerary mammae; 
deficient milk-secretion ; polygalactia ; galactorrhoea ; engorge- 
ment of the breast ; sore nipples ; mastitis ; mammary abscess ; 
arrest of lactation 320 332 

Intercurrent Diseases in the Puerperium : Miscellaneous 
diseases; malaria; puerperal anaemia; hemorrhoids; diseases 
of the urinary organs ; neuritis ; myelitis ; cerebral hemorihage 
and embolism; puerperal insanity; sudden death; pulmonary 
embolism and thrombosis ; entrance of air into uterine sinuses ; 
fever other than septic ; puerperal septic infection 332-361 

OBSTETRIC OPERATIONS. 
Episiotomy ; immediate repair of vaginal and perineal lacerations ; 
immediate repair of cervical lacerations ; induction of abor- 
tion ; induction of premature labor ; forceps operations ; ver- 
sions ; external, bipolar, internal version ; symphysiotomy ; 
Caesarean section ; Porro operation ; general rules governing 
selection of obstetric operations ; embryotomy 361-417 



OBSTETRICS. 



MENSTRUATION. 

Menstruation is a periodic discharge of blood and mucus 
from the uterus and the Fallopian tubes of the woman during 
the period of sexual activity — i. e., from puberty to the meno- 
pause. 

The cause of menstruation is unknown. Many theories have 
been advanced ; but all that can be said is that nervous influences 
proceeding from the sympathetic nerve-ganglia in the lower 
abdomen and pelvis periodically bring about a condition of 
congestion of the sexual organs. 

It is presumed that the function is analogous to " rut '^ in the 
lower animals, and that from the erect posture of the woman, 
the pelvic congestion results in bloody discharge. 

Structural changes : According to Leopold, the intra-uterine 
mucous membrane becomes thickened and softened almost to 
liquefaction, but remains practically intact throughout, while 
it is quite distinct from the j)aler muscular tissue of the uterus. 
The uterine glands are swollen and lengthened. In the super- 
ficial portion of the endometrium is an enormously distended 
network of capillaries. As the venous return is slower than 
the arterial supply, there occurs a diapedesis of blood. This 
blood, along with an excess of mucus from increased activity 
of the uterine glands, forms the menstrual discharge. 

The onset of menstruation, or puberty, varies in different 
countries, occurring earlier in southern than in northern cli- 
mates. Generally in temperate climates it appears about the 
fourteenth year. It is more likely to come on earlier in city- 
bred than in country-bred girls. 

Character of the flow: The flow is chiefly composed of 
blood, but also contains mucus and epithelial detritus. 

It has a peculiar odor, which is more marked in brunettes 
2— Obst. 17 



1 8 MENSTR IJA TION. 

than in blondes, and is caused by secretions from the sebaceous 
glands at the vaginal outlet. 

The discharge is dark in color, as a rule does not clot, and is 
alkaline in reaction. 

Duration and quantity: Menstruation lasts from three to 
seven days. As a rule, it occurs every twenty-eight days. 

The actual quantity of the discharge is from four to six 
ounces. 

Menopause : Menstruation ceases in the forty-fourth year 
usually ; but there are many exceptions. As a rule, a woman 
menstruates during a period of about thirty years. 

The cessation of menstruation is termed the vnenopause or 
climacteric. 

Ovulation : By this term we designate the process of forma- 
tion, development, and discharge of a mature ovum from its 
Graafian follicle in the ovary. 

The Graafian follicle is derived from the germinal epithelium 
on the surface of the ovary. These cells, becoming isolated in 
the stroma of the ovary, develop a special containing mem- 
brane from the theca folliculi, which becomes divided into two 
layers, the tunica fibrosa and the tunica propria. The epi- 
thelial cells develop and line this membrane, forming the mem- 
hrana granulosa, and a fluid, the liquor folliculi, distends the 
cavity. 

One of the epithelial cells of the membrana granulosa be- 
comes more highly specialized, the ovum, and is surrounded by 
an aggregation of cells, the discus proligerus (Fig. 1). 

It has been calculated that at birth each ovary contains 
35,000 immature follicles. These do not develop till about the 
time of puberty, when one or more rapidly mature and rupt- 
ure. The escape of its contents takes place each month, the 
process being repeated. 

As the follicle matures it approaches the surface of the ovary, 
the liquor folliculi increases till it points at the surface, rupt- 
ures the tunica propria and washes out the ovum surrounded 
by its discus proligerus. 

The ovum is then swept into the fimbriated extremity of the 
Fallopian tube, through \vhich it passes into the cavity of the 
uterus. 



MENSTRUATION. 



19 



? The ovum : The immature ovum is a simple epithelial cell 
without a cell-wall, but haviug cell-contents — i. e.y the yolk, a 
nucleus termed the germinal vesicle, and a nucleolus called the 
germinal spot (Fig. 2). It early develops two walls, the outer, 
termed the vitelline membrane ; the inner, the cell-membrane. 
Between these walls is a clear area, termed the zona pellucida. 
As the ovu7n matures previous to its escape from the Graafian 
follicle its germinal spot approaches the cell-membrane, where 

Fig. 1. 
PS KE PS 




Development of the Graafian follicle : KE, germinal epithelium, from which 
Pfliiger's tubes. PS, in ovarian stroma are developed ; So, ovarian stroma; g,g, small 
vessels ; L\ U, primitive ova : S, space between membrana granulosa and ovum ; Lf, 
liquor folliculi ; B, discus proligerus : Ei, ripe ovum, with germ-vesicle and ger- 
minal spot (K) : Mp, membrana pellucida ; 3y, muscular sheath of follicle ; Mg, mem- 
brana granulosa. (Wiedersheim.) 

it seems to disappear, and a portion of the ovum is extruded, 
known as the first polar body. After a stage of quiescence 
the process is repeated, and a second polar body is extruded. 

Then appears a new and smaller germinal spot, termed the 
pronucleus. 

When these phenomena have taken place the ovum is mature 
and the Graafian follicle ruptures. 



20 



MENSTRUATION. 



The corpus luteum : After the escape of the ovum the rupt- 
ured Graafiau follicle becomes filled with blood, which clots 
aud a fiue capsule develops around it, which gradually becomes 
thickened and thrown into folds. This formation is termed the 
corpus liUcum, from its yellow color. Should pregnancy not 
occur by the twenty-eighth day it shows on the surface of the 
ovary merely as a fibrous lamina in a little pit. 

But in pregnancy J from the prolonged congestion, the corpus 
luteum has a much greater development. Forty days after 

Fig. 2. 




Triangular bit of ovarian stroma cut from ovary : Magnified to show Graafian 
follicle and ovule: 1, epithelial covering of ovary; 2, tunica albuginea (fibrous); 
?., 3, different parts of stroma ; 4, Graafian follicle (tunica fibrosa) ; 5, Graafian vesicle 
or ovisac ; 6, 6, tunica granulosa ; 7, liquor folliculi ; 8, vitelline membrane, or zona 
pellucida; 9, granular vitellus, or yolk; 10, germinal vesicle ; 11, germinal spot. 

conception it has a diameter of about two-thirds of an inch 
(1.5 cm.). At term it is still present, has shrunk to half an 
inch (1 cm.) in diameter, and is of a distinct lemon-yellow 
color. A month after delivery it is reduced to a small mass 
of fibrous tissue. 

Ovulation and menstruation : Neither ovulation nor menstru- 
ation is dependent on the other. 

Both depend on the same cause, a periodic nervous excita- 



IMPREGNATION AND CONCEPTION. 



21 



tion and congestiou. As a rule, they do occur synchronously; 
but Leopold has proved that ovulation has taken place in the 
intermenstrual period. 

Pregnancy has been known to take place before the onset 
of menstruation and after the climacteric. 

PREGNANCY (Normal). 
EMBRYOLOGY. 



Impregnation and Conception. 

The propagation of the species requires the union of the 
vital elements of the two sexes. 

In the act of copulation the male deposits within the female 
a fluid, the semen, which contains the vitalizing element. 

The semen is a white, viscid, dense fluid having a peculiar 
odor, secreted by the testicles of the male. It consists of water, 
albuminous matter, salts of lime and sodium, and contains 
numerous peculiar organisms called spermatozoids. 

These spermatozoids form the essential fecundating part of 
the semen, are about -g-J-g- inch in length, and resemble the tadpole 
of the frog. Each one is mad^ up of three parts ; head, middle 
piece, and tail, and is capable of very rapid vibratory move- 
ment (Fig. 3). 

After emission, if in proper surroundings, 
the organisms retain their vitality for a con- 
siderable time. Excessively acid or alka- 
line fluids destroy them. 

While pregnancy has been known to 
follow the deposition of semen on the ex- 
ternal genitals of the female, as a rule, 
the acid mucus of the lower vagina proves 
fatal to the spermatozoids. 

At the crisis of the sexual act the semen 
is usually deposited in the upper portion of 
the vagina, into which the cervix projects. 
Hence the spermatozoids find their way into 
the cavity of the uterus, and ultimately reach the Fallopian 
tubes. They have been found on the surface of the ovary. 



Fig. 3. 




Spermatozoids. 



22 



PREGNANCY. 



As a rule, the meeting-place of the spermatozoids aod ovum 
is in the Fallopian tube. Many claim that the normal place 
of meeting is the upper })oition of the uterine cavity ; and it 
is not infrequent that they come in contact on the surface of 
the ovary or in the abdominal cavity (ectopic gestation). If 
the ovum is discharged at the height of the menstrual conges- 
tion, it probably does not reach the cavity of the uterus ibr 
some days. Hyrtle found the ovum in the uterine extremity 
of the tube in a girl who had died on the fourth day of men- 
struation. 

Pregnancy is more likely to occur after copulation during the 
first eight days succeeding the cessation of menstruation. 

Fertilization of the ovum : Of the large number of sper- 
matozoids deposited in the vagina, but few probably come into 



Fig. 4. 



„^-^r/ 




Formation of polar globules in arteria glacialis : Sp, nuclear spindle; Pfir, first 
polar globule ; Spg, second polar globule; J'p, female pronucleus. (After 0. Hert- 
wig.) 

contact with the ovum ; and of these, but a single spermatozoid 
actuallv takes part in the fertilization of the ovum. 

By friction with the walls of the tube the cells of the discus 
])roligerus disappear and the zona pellucida becomes surrounded 
with an albuminous covering which seems to attract the sper- 
matozoid. 

The successful spermatozoid, after penetrating the zona pel- 



DEVELOPMENT OF THE DECIDUA. 23 

lucida, comes in contact with a projection of the protoplasm of 
the ovum and its tail disappears. The head then penetrates 
the cell-contents and disappears, to reappear subsequently as a 
small round body, the male j^i'onucleus (Fig. 4). Finally the 
male pronucleus and the female pronucleus unite, and concep- 
tion has occurred. Thus the life-history of the embryo, foetus, 
and infant begins. 

Development of the Decidua. 

\Yhile the above-described processes have been taking place, 
leading to the fecundation of the ovum, preparations have been 
in progress for the latter's reception and nourishment within 
the uterine cavity. 

The mucous membrane lining the body of the uterus becomes 
much increased in thickness, its glands enlarging in ail dimen- 
sions. The lining membrane of the uterus during pregnancy 
is termed the decidua. 

The ovum when it reaches the uterus thus finds that a soft 
bed has been prepared for it. It soon settles and becomes 
adherent, as a result of certain amoeba-like projections (villi) 
which have formed on its surface. 

The ovum once fixed, the decidua proceeds to grow up 
around it, completely imbedding it and thus shutting it off 
from the uterine cavity. 

Subdivisions of the decidua : The decidua lining the uterine 
cavity is termed the decidua vera ; that portion on which the 
ovum has come to anchor, the site of the future ]}lacenta, is 
called the decidua serotina ; while that portion which grows 
up and surrounds the ovum is named the decidua reflexa 
(Fig. 5). 

^ Coalescence of reflexa and vera : As the ovum grows and 
distends tlie uterus, the decidua reflexa comes in contact with 
the decidua vera throughout. As a result of pressure the 
outer layers of both reflexa and vera then undergo consider- 
able atrophy. This takes place about the fourth month of 
gestation. 

Layers of the decidua: The development of the decidual 
glands leads to certain changes in the conformation of the 
decidua. These glands, dilated and straight toward the sur- 



24 



PREGNANCY. 



face, become more dilated and tortuous as they pass downward 
to the muscular uterine wall. As a result, on section the 
decidua can be seen to be composed of layers of differing com- 
pactness. 

The superficial layer is quite compact. Below this is a 
layer which, on section, has a reticulated appearance, the so- 

FiG. 5. 




Semi-diagrammatic outline of an anteroposterior section of the gravid uterus 
and ovum of five weeks : n, anterior uterine wall : h, posterior uterine wall ; c, de- 
cidua vera : d. decidua reflexa ; e, decidua serotina ; ch, chorion with its villi. 
(Modified from Allen Thomson.) 

called spongy layer, or ampullary stratum ; while below this 
again, in contact witli the muscle- wall of the uterus, is a com- 
pact layer termed the stratura compadum (Fig. 6). 

The spongy layer is of prime importance, for it is through 



CHANGES IN OVUM ; DEVELOPMENT OF FCETUS. 25 

this layer that the line of separation runs, when the decidua sero- 
tina and the decidua vera are cast off with the placenta and 
membranes at the conclusion of labor. 

In fact, the decidua may be compared to a cake, which is 
composed of two compact layers, between which is a layer of 
jam. If the attempt is made to separate these two layers of 
cake, the line of separation will run through the jam (which 

Fig. 6. 




Section through the decidua: a, amnion ; h, chorion ; c, decidua : d, uterine 
muscle : e, line of separation in the cellular layer ; /, cellular layer ; g, glandular 
layer. (Friedlander.) 

corresponds to the spongy layer of the decidua), a considerable 
portion of which w^ill come away adhering to the top layer of 
the cake, while some of it will still be left on the lower layer. 

Decidual cells : Not only do the glands of the decidua 
hypertrophy, but the interglandular structure as well ; and in 
it are developed large epithelioid cells, known as decidual cells. 

In microscopic sections of placenta or membranes these cells 
are characteristic of decidual tissue. 



Changes in the Ovum; Development of the Foetus. 

The impregnated ovum is at first a simple cell. 
Its wall is "the vitelline membrane ; its contents, the granular 
vitellus, or yolk, and a nuclem ; which latter is a complex 



26 



PREGNANCY. 



structure formed, as we have seen, of the male and female 
pronuclei, and the remains of the germinal vesicle. 

Tlie next change is known as segmentation : First the 
nucleus divides, then the yolk, thus forming two complete 
cells within the vitelline membrane. These two cells then 
divide into four, these four into eight, and so on, until a great 
number have been formed (Morula stage; Fig. 7). 




Diagram showing first stages of segmentation in a mammalian ovum. 
Thompson, after E. van Beneden.) 



(Allen 



The first division results in two cells, which differ somewhat 
both in size and appearance. This difference is perpetuated, 
so that as a result of their further division two groups of cells 
differing in size and appearance are formed. 

The larger are termed epiblastic cells, and the smaller hypo- 
blastic cells. 

The blastodermic vesicle : These two sets of cells then ar- 
range themselves in a special manner; the epiblastic cells com- 
pletely surrounding the hypoblastic cells, which collect in a 



CHANGES IN OVUM; DEVEL0P3IENT OF FCETUS. 27 
Fig. 8. 




Two further stages following segmentation (rabbit's ovum) : ep, epiblast ; 
hy, hypoblast; ftp, opening in epiblast (blastopore) not yet closed; in B, this open- 
ing has closed. 

roughly spherical mass (Fig. 8). Between these two layers of 
cells a little albuminous fluid begins to accumulate, separating 
them from one another except at one spot. The fluid rapidly 

Fig. 9. 




zp, zona pellucida ; ep, epiblast ; hy, hypoblast ; hv, cavity of blastodermic vesicle. 



28 PREGNANCY. 

collects, and the ovum now forms a distended vesicle, termed 
the blastodermic vesicle. 

At this stage the epiblastic cells completely line the blasto- 
dermic vesicle, while the mass of hypoblastic cells having 
become distended by the accumulation of fluid is flattened and 
pressed out over a small area of the epiblastic cell-lining, the 
central portion being thicker than the periphery (Fig. 9). 
This thicker part is the commencement of the embryonic area. 

It is only this part of the blastodermic vesicle which is con- 
cerned in the formation of the embryo ; the remaining portion 
being the non-embryonic part, and concerned only in the for- 
mation of the amnion and the umbilical vesicle, as we shall see 
later. 

The primitive epiblastic cells peripheral to the thickened layer 
of hypoblastic cells now disappear, leaving this portion of the 

Fig. 10. 




Transection of eighteen-hour chick embryo, showing beginning of medullary 
groove and the three layers: a, ectoderm; b, mesoderm; c, entoderm. (Manton 
collection.) 

wall (if one could look, as it were, through the vitelline mem- 
brane) somewhat clearer (area pellucida). 

The hypoblastic cells now appear as a darker streak in the 
area pellucida, termed the primitive streak ; which then devel- 
ops with a groove known as the primitive groove, which is the 
first evidence of the formation of the embryo, indicating, ap- 
proximately, the position of the future vertebrae. 

Cleavage of the hypoblastic cells : If a section be made through 
this streak, or groove, at this period (Fig. 10), the hypoblastic 
cells will be found to have separated into two layers, termed 
respectively the ectoderm (permanent epi blast) and the ento- 



DEVELOPMENT OF THE MEMBRANES. 



29 



derm (permanent hypoblast) ; while between them another 
layer has formed, derived in part from both, termed the mesO' 
denn (mesoblast). 

Cleavage of the mesoderm : In the course of time this meso- 
derm develops lateral reduplications and divides into two layers, 
the parietal and the visceral layers, inclosing spaces. The 
parietal layer unites with the ectoderm to form the somato- 
pleure ; and the visceral layer unites with the entoderm to form 
the splanchnopleure. 

The space included between the two leaves of the cleft meso- 
derm is the primitive body-cavity, or coelom, which afterward 
becomes the pleuroperitoneal cavity. 

Development of the Membranes. 

The amnion : The embryo now sinks toward the centre of 
the ovum, and as it does so the somatopleure grows up all 



Fig. 11. 



Fig. 12. 





ZP 



Fig. 11.— 7f. head of embryo : pp, tail-portion of pleuroperitoneal cavity; amc, 
tail-portion of primitive amniotic cavity ( the pr/??i?Y/ce amniotic cavity is the hollow 
space inside the double folds that rise over the back of the foetus^ : a.t.f., tail-fold of 
amnion ; ahf. head-fold of amnion : *o. somatopleure : sp. splanchnopleure : fa, false 
amnion ; hy. hypoblast ; at, alimentary canal, communicating with cavity of uv, the 
umbilical vesicle ; ZP, zona pellucida" : .4, commencing projection of allantois. 

Fig. 12.— The amniotic folds have united, inclosing amc.t, the true amniotic 
cavity : /a. false amnion, whose cavity nmc, mric.p, is continuous with the pleuroperito- 
neal cavity: at, alimentary canal, still communicating with uv, the umbilical ves- 
icle; A, stem of allantois dilating into a vesicle at x ; hy, hypoblast ; sp, splanchno- 
pleure, composed of mesoblast and hypoblast, and continuous with splanchnopleure 
of intestine ; ZP, zona pellucida. 



around it, while the splanchnopleure sinks with it. These 
somatopleuric folds thus present two surfaces, one looking 



30 PREGNANCY. 

toward the embryo, the otlier toward the outer surface of the 
ovum (Fig. 11). 

As those folds meet over the back of the embryo they coa- 
lesce, and thus form two distinct membranes (Fig! 12). The 
inner membrane, that next the embryo, forms a complete 
sac, the amniotic sac% having its origin close to the cephalic and 
caudal ends. This membrane is termed the amnion, and its 
inner surface is derived from the epiblast, and is continuous 
with the skin of the embryo, which is also epiblastic. 

The outer membrane, which has its outer surface composed 
of epiblastic cells, then retires toward the outer surface of the 
ovum, to form the chorion. 

Primitive gut- and yolk-sac : While these changes are in 
progress in the somatopleure, the splanchnopleure, sinking 
toward the centre of the ovum along with tlie embryo, com- 
pletely envelops the yolk. By bending sharply inward at a 
point some distance from its origin the splanchnopleure forms 
a second canal, which is thus lined with hypoblast. The upper 
canal eventually becomes the alimentary tract ; while the lower 
is the yolk-sac (Figs. 11-14). This latter gradually disappears, 
though it sometimes persists as a blind sac leading from the 
ileum, known as Meckel's diverticulum. 

The allantois : A portion of the splanchnopleure forming the 
wall of the primitive intestine very early buds outward, projects 
into the pleuroperitoneal cavity, and approaches the chorion. 
This is termed the allantois ; in its substance the foetal blood- 
vessels develop (Figs. 11-14). These allantoic bloodvessels 
line the chorion and dip down into the villi. 

The urachus : In the course of development, that part of the 
allantois in connection with the body becomes obliterated. A 
part forms the urinary bladder, while a portion of it persists 
as a fibrous cord running from this viscus to the umbilicus, 
termed the urachus. 

The umbilical cord : Both the yolk-sac and the allantois are 
at one time included in the tube formed by the meeting to- 
gether of the amnion on the ventral aspect of the embryo, 
termed the abdominal stalk, which becomes the umbilical cord. 

The chorion is the permanent outer membrane of the ovum, 
and is formed, as we have seen, from the somatopleuric layer, 
its outer surface being epiblastic and its inner mesoblastic. 



DEVELOPMENT OF THE PLACENTA. 



31 



The whole superficial area of the chorion soon becomes cov- 
ered with little projections, termed rdUi, which *^ dip down '' into 
and soon become attached to the decidoa (serotina and reflexa) 
at all points of contact. 

Each villus thus has an outer surface of epiblastic tissue, 
w^hile its core is formed of mesoblast. These villi, as we have 
seen, receive a vascular equipment from the allantois, though 
the more recent view is that the capillaries are simply formed 
from the mesoblastic tissue of the chorion. Subsequently those 



Fig. 13. 



Fici. 14. 




Fig. 13.— to, true amnion, its cavity, amc.t, beginning to extend with liquor 
amnii : fa, false amnion, its cavity, amc, continuous witli pleuroperitoneal cavity ; 
so.s, folds of true amnion bulging over abdomen and beginning to form sheath over 
stems of umbilical vesicle and allantois ; uv, umbilical vesicle ; zp, zona pellucida; 
A, allantois ; its stem is hollow and continuous with cavity of alimentary canal ; at 
X it is dilating into a vesicle lined Avith hypoblast. 

Fig. W.—A, allantois, its cavity now obliterated, it has spread all around, and 
joined subzonal membrane (composed of false amnion and vitelline membrane) 
to form chorion ; uv, remnant of umbilical vesicle; at, alimentary canal; o, dilated 
root of allantois within abdomen, to form urinary bladder and urachus ; w, com- 
mencing infolding of epiblast to join cavity of alimentary canal, and form mouth 
and buccal cavity : a similar notch at the caudal end of the embryo indicates site of 
future anal opening ; so.s, folds of true amnion forming sheath of navel string, and 
inclosing root of allantois and stem of umbilical vesicle. (The other letters have 
same reference as in Fig. IB.) 

villi in contact with the serotina undergo rapid development 
and proliferation, forming the chorion frondosum ; while those 
in contact with the reflexa, termed chorion Iceve, retrograde and 
finally atrophy. 



Development of the Placenta. 

Structure : The placenta is chiefly composed of foetal tissue, 
the chorion frondosum ; but the superficial layer of decidua 



32 



PREGNANCY. 



serotina separates with it, and forms its maternal surface. 
Thus the placenta is partly foetal and partly maternal, both in 
origin and structure. 

The villi forming the chorion frondosum are simply tufts of 
foetal capillaries covered with two or more layers of embryonal 
connective tissue derived from the epiblast, the outermost layer 
being termed the syncitium from its peculiar phagocytic func- 
tion. 

These villi branch in every direction, and, coming into con- 
tact with the uneven surface of the decidua serotina, often 
appear on section to have actually dipped down into it ; but 
this is only apparent, and does not really occur (Fig. 15). 

Fig. 15. 




Scheme of placental attachments: Am, amnion; Ch, chorion; V, villi; S, 
decidua serotina: D,ic., subchorionic decidua: T\, villi attached to serotina; A, 
maternal artery ; V2, maternal vein. (After Eden.) 

The maternal capillaries in the superficial layer of the 
serotina become enormously distended with blood, thus forming 
sinuses. 

Through the probable phagocytic action of the syncitial 
masses on the villi the superficial layer of the serotina and the 
walls of the maternal capillaries are in time absorbed, thus 
permitting the maternal blood to escape into the intervillous 
spaces. 



PLACENTA AND MEMBRANES AT TERM. 33 

The foetal villi are then in direct contact with the maternal 
blood — are bathed in it; but there is no actual connection 
between the foetal and maternal circulations, as the walls of 
the foetal villi and their coverings are still interposed. 

The maternal blood is carried through the decidua by means 
of spiral twigs derived from the uterine arteries ; and is carried 
away by veins having an oblique direction toward the perito- 
neal layer of the uterus. 

This formation of the arteries and veins in the decidua 
results in the absolute cutting off of the blood-supply, when 
uterine retraction and contraction bring about the expulsion 
of the placenta at birth. 

Placenta and Membranes at Term. 

The placenta at term — /. e., the end of the period of preg- 
nancy — is a soft, spongy, vascular mass, circular in outline, 
thickest at its centre, where the umbilical cord is inserted, as a 
rule. Its surface is six to nine inches in diameter ; it is from 
one-half to one and one-half inches in thickness ; and weighs 
from one to one and one-half pounds. 

The placenta is fully formed at the third month, though its 
dimensions increase steadily toward term and bear a propor- 
tional relationship to the size of the child. 

There are two aspects of the placenta to be described : first, 
the foetal, that side directed toward the foetus ; secondly, the 
maternal., that directed toward the uterus. 

The foetal aspect of the placenta is covered with a smooth 
shining membrane, which is continuous with that covering the 
umbilical cord and lining the amniotic sac, the amnion. 
Beneath this may be seen the large umbilical vessels running 
tortuously on the chorion, and dividing into branches, which 
dip down at right angles into the villi, forming the mass of the 
placenta. Deeper dow^n the darker chorion may be seen through 
the transparent amnion. The remains of the yolk-sac may occa- 
sionally be noted, looking like a piece of putty, lying a short 
distance from the insertion of the cord. 

The maternal aspect of the placenta is of a dark grayish-red 
hue, and is divided by deep sulci into lobules of irregular out- 
line, termed cotyledons. Its surface is covered by a grayish, 

3— Obst. 



34 PREGNANCY. 

glistening, transparent membrane, which is the maternal por- 
tion of the placenta, and is composed of the superficial layer 
of the decidua serotina. Therefore the line of cleavage, when 
the placenta separates from the uterine wall, is through the 
middle or spongy layer of the decidua. 

Around the periphery of the placenta runs a large vein, the 
circular sinus or vein, which returns a portion of the maternal 
blood from the organ. 

The site of the placenta in the uterus varies, though it is 
generally on the anterior or on the posterior wall. 

The functions of the placenta are many. It is at once the 
lung, the alimentary apparatus, and the kidney of the foetus. 
In it the foetal blood parts with its carbonic acid gas and its 
other waste-products, receiving in return, from the maternal 
blood, oxygen, and the materials necessary for the nutrition of 
tlie foetus. 

The epithelial layers of the chorionic villi seem to have 
certain powers of both selection and resistance; since cer- 
tain bacilli and drugs pass readily into the foetal circulation, 
while others do not. 

The umbilical cord, which unites the foetus with the placenta, 
is formed about the fourth week of gestation. It averages at 
term about twenty inches, varying from four to eighty inches, 
in length. Its thickness varies from the size of the little 
finger to that of the thumb. Its sheath is composed of am- 
nion ; it contains tico arteries carrying blood from, and a vein 
carrying blood to, the foetus, wdiich are imbedded in a mucoid 
substance known as Wharton^ s jelly. These vessels run in a 
spiral manner, the twists usually being from right to left. 

The amnion and chorion, with the shreddy remains of the 
decidua and the placenta, when they are examined after de- 
livery, are seen to form a sac, which has been ruptured at one 
spot, usually at the site of the internal os, to permit the escape 
of tlie foetus. 

The decidua on the membranes is somewhat thicker than 
that on the maternal aspect of the placenta, since it consists of 
the atr()j)hied reflexa and the superficial layer of the vera. It 
is reddish in color and very friable. 

The chorion can be readily separated from the amnion, each 
of these forming a distinct membrane as far as the edge of the 



THE VUM AT DIFFERENT PERIODS OF PREGNANCY. oO 

placenta. The chorion will be noted to be thicker, more 
opaque, and less tough than the amnion. 

The amnion, which is the membrane next to the foetus, is a 
clear, translucent membrane whose chief characteristic is its 
toughness. This toughness permits the sac, when distended 
with liquor amnii, to withstand considerable pressure, and 
enables the bag of membranes to act in an efficient manner as 
a hN'drostatic dilator during the first stage of labor. 

The liquor amnii, which fills the amniotic sac and in which 
the foetus is suspended, is a light-colored turbid fluid of a 
specific gravity of about 1010. Its quantity varies from one 
to two pints in the normal state. Its source is not definitely 
known. By many it is believed to exude from the maternal 
vessels in the uterine walls, but it is probably of foetal origin. 

Its fiinctio)i is to prevent the foetus being pressed upon, and 
to allow its free development. Shocks, due to falls or blows on 
the part of the mother, are prevented from affecting the foetus. 
During labor, as has been said, it forms the most perfect di- 
lator of the cervix, and protects the child from the great press- 
ure brought to bear on the uterine contents during the first 
stage of labor. 

The Ovum at Different Periods of Pregnancy. 

First month: At the end of the fourth week the ovum 
measures about 1 inch in diameter, and the straightened-out 
embryo about J inch. The chorion is covered with villi, and 
the amnion does not quite fill the cavity of the chorion, the 
space separating them containing a clear fluid. 

Second month : At the end of this month the ovum is nearly 
2 inches in diatneter, and the embryo | inch long. The 
amnion fills the chorion. The chorion Iseve is atrophying, but 
the cord is not yet twisted and contains a loop of intestine at 
its base. 

Third month : By the twelfth week the ovum is 4 inches 
in the long diameter, and the foetus, as it is now called, is 
about 3J inches (7-9 cm.) in length. The placenta is com- 
pletely formed and the rest of the chorion is quite free from 
villi. The cord is twisted and the loop of intestine has been 
withdrawn into the abdominal cavity. 



36 PREGNANCY. 

Fourth month : At the end of the sixteenth week the foetus 
measures about 6 inches (17 cm.) in lengtli. The head is pro- 
portionally very large. The sex can be distinguished. Lanugo 
is present. 

Sixth month : The average length of the foetus is now about 
12 inches (28-34 cm.), and it weighs about 23 J ounces (676 
gm.). The testicles in males are still in the abdominal cavity. 

Seventh month : At the end of this month the foetus meas- 
ures in length 13.75 to 15 inches (35-38 cm.), and weighs 41 J 
ounces (1170 gm.). The whole body is covered with lanugo, 
except the palms of the hands and the soles of the feet. The 
pupillary membrane disappears. 

Eighth month: The foetus now measures 15 to 16 inches (39 
to 41 cm.) in length and weighs 3 J pounds (1571 gm.) Lanugo 
is disappearing from the face, and the left testicle is in the 
scrotum. Ossific centres are present in the lower epiphyses of 
the femurs. The child if born is viable. 

Ninth month : At the end of this month, the thirty-sixth 
week, the foetus averages about 5J pounds in weight. At this 
period, if the infant should be born, Hirst considers that with 
ordinary care it should certainly live. 

The consideration of the infant at full term, the fortieth 
week, will be taken up under the heading Labor ; but it is con- 
venient at this point to refer to the peculiarities of foetal circu- 
lation. 

Foetal Circulation (Fig. 16). 

The foetal blood, having been oxygenated in the terminal 
villi in the placenta, is returned by various branches to the 
umbilical vein. This is carried along the cord to the foetal 
body, which it enters at the umbilicus. It runs thence along 
the anterior abdominal wall to the under surface of the liver, 
where it branches, the larger branch emptying into the portal 
vein, while the smaller, called the ductus venosus, empties 
directly into the ascending vena cava. 

Thus the largest quantity of the " arterial '^ blood from the 
placenta must pass through the fcetal liver, where it probably 
undergoes some changes before entering the general circulation. 

Hence is poured into the right auricle of the heart, from the 
ascending vena cava, a stream of blood derived from (1) the 



FCETAL CIRCULATION. 



37 



Fig. 16. 



hepatic veins ; (2) the 
ductus venosus ; and (3) 
the lower extremities of 
the foetus along the iliac 
veins. 

This mixed stream en- 
ters the right auricle pos- 
teriorly, is guided across 
it by a fold of membrane, 
termed the Eustachian 
valve, through the fora- 
men ovale, an opening in 
the inter-auricular sep- 
tum, and thus enters the 
left auricle. 

The Eustachian valve, 
by directing the blood- 
current from the right 
ventricle, thus " short- 
circuits '' the stream 
from tlie undeveloped 
foetal lungs, which in 
their uuexpanded con- 
dition could not contain 
such a large quantity of 
blood. 

From the left auricle 
the blood enters the left 
ventricle, passing thence 

Diagram of the circulatory 
organs "of the human f(ietus at 
six months: HA. right auricle; 
HV. right ventricle: LA, left 
auricle : Ev. Eustachian valve : 
L. liver : K. left kidney ; J. part 
of small intestine: a. aortic 
arch : a', its dorsal part : a", 
posterior end of abdominal 
aorta : ves, superior vena cava ; 
rci, inferior vena cava near its 
junction Avith the right auricle ; vei', posterior part of inferior cava : s, subclavian 
vessels ; ./. right jugular vein : c, common carotid arteries : the four dotted arrow- 
lines indicate the course of the circiilation ; da, ductus arteriosus: an arrow-line 
starting at vci indicates the course of blood-flow from the inferior cava through the 
foramen ovale : hv, hepatic veins ; rp, vena ports ; x to vci, the ductus venosus : ?n', 
umbilical vein ; ua, umbilical arteries ; nc, umbilical cord ; i, i, iliac vessels. (Allen 
Thomson.) 




38 PREGNANCY. 

to the aorta. The greater part of the stream is then directed 
through the carotids to the head, a small quantity only con- 
tinuing along the aorta. 

The venous l)l()od returning from the head is collected in the 
descending vena cava, and passing thence into the right auricle 
anteriorly, it finds its way into tTie right ventricle. It is then 
forced into the pulmonary artery, whence it passes by another 
" short circuit,'' termed the ductus arteriosus, emptying into the 
aorta just beyond where the carotids branch to the head ; only a 
sufficient quantity for their nutrition being directed to the lungs. 

This venous blood then descends along the aorta, the larger 
quantity passing thence to the iliac arteries, from the internal 
pair of which two arteries pass directly to the umbilicus, and 
thence along the cord to the placenta. These arteries within 
the body are termed the hypogastric arteries. 

Thus the lower limbs of the foetus receive but a poor supply 
of what is practically venous blood ; hence their poor develop- 
ment at birth as compared with the head, which receives a rich 
supply of fairly freshly oxygenated blood. With the expan- 
sion of the lungs at birth the whole course of the circulation 
changes to that which persists throughout life. 



CHANGES IN THE MATERNAL ORGANISM RESULTING 
FROM PREGNANCY. 

Uterus. 

The increase in the size of the uterus takes place chiefly in 
the body of that organ. 

The cavity of the body increases in length from 11 inches 
(3.7 cm.) in the unimpregnated state, to 12 inches (00.5 cm.); 
the width, from 1 J inches (3.2 cm) to 9 inches (23 cm.) ; the 
depth (anteroposterior), from nothing to between 8 and 9 
inches (20-23 cm.). The capacity is increased from nothing 
to about 500 cubic inches (8300 c.cm.). 

The weight of the organ increases from 1 ounce (30 gm.) to 
about 24 ounces (720 gm.). 

These measurements vary with the size of the foetus, the 
quantity of liquor amnii, and in multiple pregnancy. 

This increase in size is a growth, and not a mere distention, 



I 



UTERUS. 39 

for in ectopic gestation the uterus is found to go on growing, up 
to and beyond the fourth month. 

The changes in shape are characteristic. In the non-preg- 
nant condition the uterus is pyriforni, the large end being 
uppermost ; and flattened anteroposteriorly. 

In the earlier months of pregnancy the lower part seems to 
increase in capacity faster than the upper, so that the shape of 
the uterus becomes roughly spherical ; while at the fifth month, 
according to Webster, the organ is once more pyriform in 
shape, but the widest part is lowermost. 

At the end of pregnancy the uterus assumes very much the 
shape of the non-pregnant organ, the roomiest part being again 
uppermost. 

Thus up to the fifth month the increase in the capacity of 
the uterus is chiefly in its lower part ; and from then till term 
mainly in its upper portion. 

Muscle-fibres : The marked increase in the bulk of the uterine 
wall during pregnancy is mainly due to hypertrophy of the 
muscle-cells, Helme states that there is no hyperplasia, but 
that the existing fibres increase from seven to eleven times in 
length and from three to five times in breadth. 

The arrangement of these muscle-fibres \w\\\ be discussed 
later under the heading of anatomy of labor. 

The connective tissue of the uterus increases in proportion 
to the muscular. There exists a true hyperplasia of the con- 
nective tissue, which begins in the neighborhood of the blood- 
vessels. 

The arteries of the uterus become markedly increased in 
calibre and length. At the placental site there is a spiral 
arrangement of the arterial twigs, as they penetrate the uterine 
decidua and empty into the lacunae. The veins become cor- 
respondingly increased in size. In fact, the uterus may be 
regarded as a huge venous plexus during pregnancy, as the 
blood-supply is so great. The walls of these veins are reduced 
to the intima, so that after labor the mere contraction of the 
uterine muscle-fibres is sufficient to obliterate their lumen. 

The lymphatics of the uterus become increased both by hy- 
pertrophy and hyperplasia. Beneath the decidua enormous 
lymph-spaces develop, the tubes or vessels leading from these 
to the lymphatic plexus beneath the peritoneal layer of the 



40 PREGNANCY. 

uterus reaching the size of goose-quills. This condition of 
the uterine lymphatic system explains the remarkably rapid 
absorption of the uterus after labor, as well as that of septic 
material from the uterine cavity. 

The nerves of the uterus take part in the general develop- 
ment, the increase being chiefly in the primitive sheath, and 
not in the nerve-substance. 

The ligaments of the uterus hypertrophy during pregnancy, 
and their relationships become altered with the elevation of 
the fundus in the abdominal cavity. 

The connective tissue throughout the pelvis becomes succu- 
lent and distensible. 

Uterine contractions : Throughout pregnancy the uterus is in 
a state of alternate contraction and relaxation. This condition 
favors the circulation of the maternal blood in the uterine wall 
and placental sinuses. These contractions may be noted as soon 
as the fundus becomes accessible to examination from the ab- 
dominal surface. 

Relation to Pelvis and Abdomen. 

Up to the third month, while the uterus has increased in size 
and become quite globular in form, its level in the pelvis has 
undergone no marked change. It has become somewhat more 
anteflexed, and from its weight has sunk down somewhat into 
the pelvis, the cervix being carried backward, so that on mak- 
ing a vaginal examination at this period, the anterior uterine 
wall can be readily felt and seems to bulge forward. 

By the end of the third month the fundus uteri has risen to 
the brim of the pelvis, and may be felt on moderately deep 
pressure just above the symphysis pubis. 

By the end of the fourth month the fundus is in contact with 
the anterior abdominal wall. 

At the sixth month it reaches the level of the umbilicus. 

At the seventh month it is half-way between the umbilicus 
and the xiphoid cartilage. 

At the ninth month it is up to the level of the lower ribs ; 
but within about two weeks of labor it falls forward somewhat, 
and seems to be on a slightly lower level, on account of the 
descent of the presenting part of the foetus into the brim of the 
pelvis. 



CHANGES IN THE BREASTS. 41 

The intestines are displaced upward by the uterus as it 
asceuds, so that on percussion a dull note is obtained over the 
whole central part of the abdomen. 

There is a certain amount of dextro-rotation of the uterus 
retained throughout pregnancy, so that the organ leans some- 
what to the right as a rule. This right obliquity of the uterus 
may be accounted for by its relation to the sigmoid flexure and 
descending colon, the left side of the organ being pushed for- 
ward by these structures. 

Alterations in the Cervix. 

There are two conditions of the cervix during pregnancy 
which are peculiarly characteristic. Both are due to a partial 
obstruction in the venous return which leads to softening and a 
marked blue or violet discoloration. 

The softening of the cervix begins, as a rule, about the second 
month. It is first apparent about the tip, but spreads upward 
as pregnancy advances, so that in the later months the 
whole cervix becomes so soft that the finger, if unaccustomed 
to vaginal examination, may liave difficulty in finding the os 
uteri. The cervix in pregnancy has been likened in feel to 
that of the pouted lips. 

The violet discoloration is due simply to the venous engorge- 
ment, and it may be present even in the first few weeks of 
pregnancy. The canal of the cervix remains throughout preg- 
nancy unaltered in length. Its mucous glands secrete a 
peculiarly tough mucus, which stops up the canal like a cork 
throughout pregnancy (mucous plug). 

Vagina, Vulva, and Breasts. 

The vagina and vulva become somewhat hypertrophied 
during pregnancy. The color of the mucous membrane 
becomes bluish. There is a slightly increased secretion of 
mucus, and the parts become lax and soft. 

Changes in the Breasts. 

With the onset of pregnancy there is an increased deter- 
mination of blood to the breasts; and certain alterations pre- 
paratory to the function of lactation begin. 



42 



PREGNANCY. 



These glands attain complete development in the first preg- 
nancy. 

Tlie lobules enlarge and become distinct from one another. 

The epithelium lining the acini becomes active, leading to a 
certain amount of desquamation of the upper layers. 

These cells undergo fatty degeneration and are set free, con- 
stituting colostrum-corpuscles. 

Very early in pregnancy a small quantity of serum may be 
expressed from the nipples. 

The fat and connective tissue surrounding the lobules hyper- 
trophy, and the breasts become enlarged and more prominent. 

Coincident with these changes there is increased tenderness 
on ])ressure. 

The skin becomes stretched and striae develop, having a 
radial distribution and direction. The veins on the surface 
become more obvious. 

The areola becomes darker from deposit of pigment, this 
being more marked in brunettes than in blondes (Fig. 17). 



Fig. 17. 




Brunette: Wrinkling of primary areola; S. A., well-defined secondary areola. 
(Dickinson.) 

The sebaceous follicles of the areola, ten or twenty in num- 
ber, become more prominent, being of lighter color. These 
follicles at the margin of the areola being uncolored, stand out 
prominently as white spots, forming tlie so-called secondary 
areola. 

The nipples become more prominent as a rule, and are softer 



ALTERATIONS IN OTHER THAN GENERATIVE ORGANS 43 

than in the non-pregnant state. In the later months of preg- 
nancy dried cakes of secretion may be fonnd encmsted on their 
surface. 

Alterations in Other than the Generative Organs. 

Nervous system : There is present during pregnancy a condi- 
tion of exalted nerve-tension. Hence there is an increased 
tendency to nerv^ous instability. The woman is more prone to 
hysterical attacks. There are often present perversions of taste, 
smell, etc. ; also neuralgia, especially of the face and teeth. 
Mental affections are apt to develop during this period. 

This condition of increased nerve-tension causes about two- 
thirds of all pregnant women to suffer from vomiting at some 
time or another of their pregnancy. 

This so-called vomiting of pregnancy begins, in a large ma- 
jority of cases, early in the second month ; it usually persists 
during the second and third months, but may last throughout 
pregnancy. It may be looked upon as one of the symptoms of 
the pregnant condition. 

It usually occurs on first rising in the morning, and may be 
mild or sufficiently severe to endanger the woman's life. 

The essential exciting cause of the vomiting probably origin- 
ates in the physiological uterine contractions occurring through- 
out pregnancy (see Pernicious Vomiting). 

Circulatory system : The total quantity of blood is increased. 
The quality is also changed, there being an increase in fibrin 
and white corpuscles; while the red corpuscles and albumin 
are diminished. 

The heart, probably as a result of the changes in blood 
quality, undergoes some dilatation ; but as the quantity of the 
blood is increased there is a perfectly compensatory hypertrophy 
which is more marked on the left side. Both spleen and thyroid 
gland increase in size. 

Respiratory system : As the range of movement of the dia- 
phragm becomes interfered with by the uterus the thorax 
widens to a slight extent. Owing to increased oxidation-proc- 
esses, the work of the lungs is augmented. 

There is but little change in the alimentary system. The 
digestive processes are somewhat more active, and, as a rule, 
the appetite is increased. Digestive disturbance is common. 



44 PREGNANCY. 

Urinary system : The urine is increased in quantity and is 
more watery, the specific gravity being about 1014. The 
quantity of urea excreted is normal. 

Cutaneous system : The functions of the skin are increased 
during pregnancy. 

Pigmentat'ion is increased. There is, as a rule, a marked 
deposit of pigment over the linea alba, so much so as to con- 
stitute one of the signs of pregnancy ; it may reach from the 
pubes to the ensiform cartilage. The skin around the eyes is 
darkened, and frequently irregular spots of pigment appear on 
the surface of the body, chiefly in the face. 

Lineae albicantes : Certain skin-cracks are to be noticed, 
chiefly as a result of over-stretching. They are termed strice, 
linece albicantes, linece matenice, or linece gravidarum^ and appear 
usually on the skin of the abdomen and breasts. They run 
usually in the lines of tension, and are due to yielding of the 
corium in stretching, the epidermis being continuous over them 
without any change in structure. They vary in length up to 
two or more inches, and when recent are red in color. Later 
on, as a result of scar-formation, they become white, and form 
strong presumptive evidence when present of previous preg- 
nancy. 

DURATION; DIAGNOSIS; HYGIENE AND MANAGE- 
MENT OF PREGNANCY. 

Duration of Pregnancy. 

As a rule, it is impossible to predict exactly the date when 
labor will take place. 

If the date of fruitful coitus can be fixed, then labor will 
most likely set in two hundred and seventy-one days later, 
according to Ahlfeld. 

The common rule is that labor will occur on the day of the 
tenth menstrual period — i. e., two hundred and eighty days 
after the first day of the last menstruation. Allowance must 
always be made for the short month February. 

As a rule, one seldom predicts the exact day of labor, and the 
variation of a week or two is far from common. 

When pregnancy occurs during a period of amenorrhcea, as 



FIBST TRIMESTER— SUBJECTIVE SYMPTOMS. 



45 



lactation; or if the date of the last menstruatiou cannot be 
ascertained, then the probable date of labor may be fixed by 
noting the height of the fundus : 

The following table has been given by Satngiu and Galabin : 



Weeks . 


. 16 


Inches . 


. 4 


Cm. . . 


. 10 



20 


24 


28 


32 


34 


36 


38 


5.4 


6.6 


7.8 


8.7 


9 


9.3 


9.6 


13.5 


16.5 


19.5 


22 


23 


23.5 


24 



40 
10 
25.5 



This nietiiod can only be employed in cases where the head 
presents at the brim of the pelvis. The measurement is made 
by placing one tip of a pair of calipers on the symphysis pubis 
and the other on the fundus uteri. 

The date of quickening — i. e., the first occasion on which the 
mother feels the movements of the foetus — is of some value in 
estimating the duration of pregnancy. Quickening occurs in 
the twentieth week as a rule in primiparse ; and in the twenty- 
first or twenty-second week in multiparse. 

Diagnosis of Pregnancy. 

The recognition of pregnancy is not always an easy matter, 
especially in the earlier months of gestation. 

Careful, systematic, and, if necessary, repeated examination 
cannot fail to permit a certain diagnosis being made. 

Failure in diagnosis is nearly ahvays the result of careless 
and unsystematic examination. 

For convenience of study the nine calendar months of preg- 
nancy may be divided into trimesters ; and a classification of 
the symptoms and signs as to these three periods be made. 



First Trimester — Subjective Symptoms. 

The suppression of menstruation constitutes, as a rule, the 
first evidence of pregnancy. This function is usually sus- 
pended throughout gestation ; but this is not invariable. Some 
women menstruate at least once, and occasionally several times 
after the occurrence of pregnancy. The value of this sign as 
evidence is less in w^omen who are very irregular in menstru- 
ating. 

Causes: Suppression may result from exposure to cold; 



46 PREGNANCY. 

from the preseuce of debilitating disease, as tuberculosis, 
anaemia, etc. ; over-anxiety or marked fear of pregnancy may 
produce this result, as may also sudden mental shock ; change 
of climate or surroundings occasionally act in the same way. 
These exceptions should be held in mind ; but suppression of 
menstruation in a healthy woman of regular habit usually 
means pregnancy. 

Nausea and vomiting, occurring in the morning especially, 
form one of the most common symptoms of pregnancy. 

The sensation usually conies on when the woman first as- 
sumes the erect position in the morning, hence the term ^'morn- 
ing sickness ^^ commonly applied to it. 

These symptoms, as a rule, appear in the fourth or fifth week ; 
but may occur even earlier. They cease, as a rule, about the 
fourth month ; but may persist throughout pregnancy. The 
causation has already been referred to. 

The mammary changes begin as early as the second month, 
the congestion of the parts causing a sensation of fulness, with 
tingling and tenderness. Increase of pigmentation about the 
areolae and the presence of serum in the lacteal ducts become 
apparent during the third month. 

Vesical irritation is often complained of very early in preg- 
nancy. As a result of the increase in the normal anteversion 
of the uterus, the bladder is pressed upon and its functions in- 
terfered with ; this usually persists till the fourth month. 

Frequently digestive disturbances arise early in pregnancy, 
having a reflex origin. The appetite becomes capricious, and 
acidity is common. 

Nervous disorders, which are purely functional, are not infre- 
quent. Ptyalism is not uncommon, and may persist throughout 
gestation. Neuralgias, cardiac disturbances, mental perturba- 
tion and irritability frequently manifest themselves very early 
and are often very persistent. 

First Trimester — Objective Signs. 

These are confined chiefly to the uterus and the breasts. 

Tiie softening of the cervix uteri begins in the first month 
of pregnancy. The whole cervix, beginning first at the external 
OS, gradually softens as a result of the physiological uterine 




FIBST TRIMESTER— OBJECTIVE SIGNS. 



47 



coDgestion. This change is most marked in the primipara, 
but is also present in the multipara. The cervix becomes 
plugged with mucus as a result of the increase in the activity 
of the cervical mucous membrane. 

A violet discoloration of the mucous membrane of the 
cervix, vagina, and vulva may be noted on inspection of these 
parts, beginning as early as the fifth week in many cases. 
This discoloration, being due to a certain degree of venous 
stasis, becomes more marked as pregnancy advances ; it shades 
from a pale violet tinge to a dusky bluish hue. 

The softening and enlargement of the body of the uterus 
consequent upon pregnancy may be readily made out by care- 
ful combined examination. Hegai'^s sign (see below) of early 
pregnancy depends upon the presence of these changes, and 
may be obtained as early as the eighth week. As a result of 
the presence of the ovum in the upper segment of the uterus, 
all the diameters of the latter become increased, , while the 
empty lower segment simply becomes softened and perhaps 
rather thinned out. 

On bimanual examination the bulky, partly softened cervix 
can be felt ; just above this is a very soft compressible area ; and 

Fig. 18. 



resilient 




PujiiiQ 

contracnon 



Changes in the pregnant uterus of the sixth week : on the left when relaxed, ou the 
right when contracting. (Dickinson.) 

above this again the boggy rounded fundus uteri may be dis- 
tinguished (Fig. 18). The sensation conveyed to the exam- 



48 



PREGNANCY. 



iner's finger is that the cervix is joined to tlie body of the 
uterus by two longitudinal bands (Hegar^s sign). This is 
best obtained by placing the thumb of the right hand in the 
anterior vaginal fornix and introducing the forefinger of the 
same hand into the rectum, then the left hand placed over the 
pul)is presses the uterus downward so that the cervix and 

Fig. 19. 



A. 







Bimanual examination for compressibility of the isthmus at the sixth week. 
(Dickinson.) 



lower part of the body may be grasped between the thumb 
and forefinger of the right hand ; or as shown in Fig. 19. 

In the third month the body of the uterus is felt to be en- 
larged and rounded as well as softened ; while the whole organ, 
which pretty well fills the pelvic cavity, is in a position of 
marked anteversion as a rule. 



Second Trimester. 

In this period the subjective symptoms are : (1) continued 
absence of menses; (2) the passing away of the troublesome 
nausea and vesical irritation ; (3) the sensation of " quicken- 
ing"- 



J 



-i, e.y fcetal movement. 



SECOND TRIMESTER. 49 

The objective signs are : (1) enlargement of the abdomen ; 
(2) progressive changes in the mammae; (3) progressive 
changes in the uterns ; (4) the feeling of uterine contractions 
and of the foet(d movements by the examiner ; (5) auscultation 
of foetal heart-sounds ; (6) hallottement. 

In the fourth month the fundus becomes easily accessible 
from the anterior abdominal wall ; hence at this period for the 
first time may be felt the irregular intermittent uterine contrac- 
tions which continue throughout pregnancy. These contrac- 
tions take place at intervals of from ten to twenty minutes, and 
lead to marked hardening of the whole uterine tumor. 

Foetal movements, or quickening, are usually first noticed 
by the mother about the twentieth week. As pregnancy ad- 
vances these movements become more marked and constant, 
and may be best obtained by the physician by suddenly placing 
his cold hand on the mother's abdomen over the uterus. 

On auscultation a loud bruit may be heard over some portion 
of the uterus as early as the fourth month. This sound has 
been termed the "uterine souffle." It is synchronous with the 
maternal pulse, and is very uncertain in its duration and place. 
It is heard not only during pregnancy, but it is occasionally 
assciated with the presence of interstitial fibroids and with ova- 
rian tumors. 

The foetal heart-sounds may be heard as early as the twen- 
tieth week by skilled examiners. They are heard best while 
the patient is in the dorsal position with the abdominal wall 
relaxed, and with the bell of the stethoscope resting lightly in 
contact with it. If pressure be made on the bell, or even if it 
be held in place by the hand, the sounds cannot be heard so 
well. 

The rate of pulsation varies from 120 to 150 per minute, 
being slower in males than in females. The sounds are 
double, the first being somewhat clearer than the second. The 
sounds of the foetal heart have been very aptly compared to 
those of a watch ticking under a pillow. The foetal heart- 
sounds bear no relation to, and are quite distinct from, the 
maternal pulsations. 

By the sixth month, the fundus having reached the level of 
the umbilicus, which has become flattened out, the abdomen has 
become quite prominent. 

4— Obst. 



50 



PEEG NANCY. 



At this time also a brownish pigmentation may be noted ex- 
tending from the pubes up to and beyond the umbilicus. 

Ballottement, one of the most valuable signs of pregnancy, 
becomes available late in the fourth month. It is a passive 
movement of the fcetus obtained by its sudden displacement 
from below by the examiner (Fig. 20). While placing the 



Fig. 20. 




.-o«Jajl[ii „,_ 



Internal ballottement, semi-recumbent posture, at sixth month. (Dickinson.) 

forefinger of the right hand in the anterior vaginal fornix, 
one may by a brisk impulse displace the foetus upward, which, 
as it resumes its original position, conveys a gentle tap to the 
finger-tip held in the vagina. Ballottement can only be simu- 
lated by a small cystic ovarian tumor having a long pedicle. 



Third Trimester. 



The subjective symptoms in this period are: (1) continued 
absence of menstruation ; (2) foetal movements ; (3) pressure- 
symptoms. 



SUMMARY OF DIAGNOSIS. 51 

The objective signs are : (1) continued enlargement of the 
abdomen; (2) continued mammary and uterine changes; (3) 
development of striae on abdomen and breasts. 

Owing to the great enlargement of the uterus pressure- symp- 
toms become very marked in many cases, ^'^arlces of the lower 
limbs and vulva, often accompanied by oedema, become more 
or less marked. Constipation from pressure on the rectum, 
and vesical Irritation from displacement of the bladder upward, 
are common. 

Disturbances of digestion and of respiration are common, both 
resulting from the great abdominal distention. 

The movements of the fcstus can be plainly seen through the 
abdominal wall. 

The skin on the abdomen frequently shows linear markings, 
which appear as red radiating striae, chiefly on the lower quad- 
rants. 

The umbilicus becomes prominent, and there is an increase in 
the deposit of pigment in the middle line. 

" Settling " : Within two weeks of labor the presenting part 
of the foetus partially enters the brim of the pelvis, becoming 
more accessible to the examining finger. The cervix also be- 
comes somewhat thinned out and feels shortened. At this time 
the prominence of the abdomen becomes less marked. 

To these changes occurring in the last two weeks prepara- 
tory to labor the term " settling '' has been applied. 

The mammary changes continue to become more marked, and 
colostrum can be expressed from the nipj)les. 

Summary of Diagnosis. 

The presumptive evidences of 'pregnancy are: (1) menstrual 
suppression ; (2) morning sickness ; (3) irritable bladder ; (4) 
mental and emotional phenomena. 

The probable evidences are : (1) mammary changes ; (2) 
abdominal chauges (e. g.^ size, shape, markings) ; (3) uterine 
changes (size, shape, color, and consistency of cervix) ; (4) 
uterine contractions and bruit. 

The only positive signs are festal: (1) foetal heart-sounds; 
(2) foetal movements ; (3) ballottement. 



52 PREGNANCY. 

Differential Diagnosis of Pregnancy. 

The physician is not infrequently called upon to make an 
examination where the patient either feigns, desires, or, more 
commonly, conceals the condition of pregnancy. The diffi- 
culties of diagnosis are much greater before the fourth month 
of gestation ; but careful systematic examination will scarcely 
fail to establish a certainty in the majority of cases. Care 
must be taken not to express an opinion until a reasonable cer- 
tainty of the condition present is obtained. 

First Trimester. 

In this period the following conditions may resemble preg- 
nancy : amenorrhoea ; subinvolution ; metritis ; uterine fibroid ; 
retained menses ; malignant disease ; tumors in the neighbor- 
hood of the uterus, as ovarian growths; salpingitis ; and ectopic 
gestation. 

Simple amenorrhoea accompanied by symptoms of gastric 
irritation may very closely resemble pregnancy ; but a careful 
bimanual examination will demonstrate the absence of uterine 
changes. 

In subinvolution the uterus does not increase in size, and it 
is not globular ; while its texture is harder than that of the 
organ in pregnancy. 

In metritis the uterus, while enlarged, is sensitive to the 
touch, and is hard and dense. Its shape is that of the unim- 
pregnated organ simply increased in size. 

An interstitial fibroid of the uterus may be distinguished by 
its denseness and by the irregular contour. Menstruation, in- 
stead of being absent, is, as a rule, increased. 

Retained menses may cause an enlargement of the uterus ; 
but in such cases the fact that menstruation has never been 
established, and a history of abdominal pains occurring at 
monthly intervals, will indicate the nature of the case. 

In malignant disease of the uterus the menstruation is, as a 
rule, increased, and intermenstrual hemorrhages occur. 

In ovarian tumors the uterus is not affected and menstrua- 
tion })er8ists as a rule. The tumor is usually situated to one 
side of the uterus and causes some displacement of that organ. 



DTAGNOSTS OF PARITY OR NULLIPARITY. 53 

Ectopic gestation may simulate uterine pregnancy ; but care- 
ful examination will reveal the prer^ence of a tumor outside 
the uterus. 

In the Later Months of Pregnancy 

the following conditions may lead to an error of diagnosis : 
obesity, ascites, tympanites, phantom tumor, and large ovarian 
or fibroid tumors. 

In obese women with irregular menstruation it is not infre- 
quently difficult to establish a diagnosis of pregnancy ; but the 
absence of mammary changes and auscultatory signs will clear 
up the case. 

In ascites a diagnosis may be made by placing the })atient in 
the dorsal decubitus and percussing the abdomen. Both flanks 
will give a dull note, while the middle area of the abdomen 
will be clear. Fluctuation may be obtained ; and on changing 
the position of the patient the area of dulness will alter. 

In tympanites, the whole abdomen, while enlarged, gives a 
clear note on percussion. The bimanual examination in both 
the above conditions will reveal the unimpregnated condition 
of the uterus. 

Phantom tumors, which are occasionally met with in hysteri- 
cal women, can be recognized on applying the usual tests of 
auscultation, percussion, etc. 

Pseudocyesis, or spurious pregnancy, is a very interesting 
condition met with usually in women about the time of the 
menopause. The woman imagines herself to be pregnant, and 
develops many of the characteristic symptoms of that condi- 
tion. Enlargement of the abdomen, fulness and tenderness of 
the breasts, may mislead the careless examiner; but in both 
the above classes of cases the administration of an anaesthetic, to 
permit of a thorough examination, will clear up the diagnosis. 

Ovarian and fibroid tumors, if large, may cause distention of 
the abdomen ; but in these cases the absence of all signs of a 
foetus will suffice to distinguish the conditions from pregnancy. 

Diagnosis of Parity or Nulliparity. 

Certain mechanical effects are produced on the abdominal 
wall and birth-canal of a woman who has previously borne a 



54 PREGNANCY. 

full-term child, ^vhicll time fails quite to eradicate. On these 
depends the diagnosis of parity or nulli])arity. 

If the ovum has been discharged before it was sufficiently 
large to produce these changes, then it is practically impossible 
to be certain as to parity. 

These signs consist of changes in the breasts, perineum, 
vagina, and cervix, as well as laxity and striie of the abdom- 
inal wall. 

In the parous woman the breasts are apt to be well developed 
and somewhat pendulous, the nipples being large and promi- 
nent. Occasionally stride may be noticed. 

The abdominal wall is lax and yielding, the skin being 
marked with white striae. 

The perineum may show marks of laceration and be some- 
what lax ; the four(;hette being absent. 

The vagina is capacious and lax, the walls being somewhat 
smooth. The remains of the hymen may be noticed as forming 
numerous small caruncles (carunculse myrtiformes). 

The cervix is short and broad ; very often it is lacerated, 
generally on the left side. 

Diagnosis of Life or Death of Child. 

It is not always easy to decide that the child is dead. The 
woman may suspect this to be the case because of certain vague 
sensations of coldness about the pubes, and because of a feeling 
of weight or dragging. She may cease to feel the movements 
of the foetus. 

The matter can only be settled if after repeated examination 
the physician fails to hear the foetal heart or feel foetal move- 
ments. If at the same time the uterus ceases to grow, and the 
breasts become flabby, it may be inferred that the child has 
perished. 

Hygiene and Management of Pregnancy. 

While the condition of the pregnant woman is a purely 
physiological one, it must be borne in mind that the border- 
line between health and disease may be very easily passed. 
Hence it is the duty of the physician to give every woman 
engaging his services for her confinement such hygienic instruc- 
tion as she may require. In fact, a certain degree of pro- 



HYGIENE AND MANAGEMENT OF PREGNANCY. 55 

fessional attention should be given to all women throughout 
the whole period of pregnancy. 

Diet: The diet during pregnancy should be plain. Simple, 
easily digestible, and highly nutritious food should be taken at 
regular intervals. Overeating, especially in the later months, 
should be guarded against. Meat should be eaten but once 
daily, and fruit, both cooked and fresh, shoidd form a prin- 
cipal part of all meals. 

Exercise : All violent exercise should be avoided. Walks 
in the open air and simple gymnastics within doors should be 
indulged in daily. All lifting and straining should be avoided. 
Bicycling may be permitted in moderation, but not over rough 
roads. The same applies also to carriage-driving. 

Clothing should be worn in such a manner as to avoid undue 
pressure upon either chest or abdomen. The corset, if wo];ii 
at all, should be a short one and should be very loose. AVomen 
with lax abdominal walls should wear an abdominal support 
so arranged that the pressure is exerted upward. 

Bathing should be indulged in daily, especially since the 
function of the skin is increased during pregnancy. If the 
woman is in the habit of taking cold baths daily, they may be 
continued, but the initial shock may be avoided by having the 
bath warm at first, and then adding cold water to it. In the 
later months at least two warm baths per week should be taken. 
Very hot and very cold baths should be avoided. 

The care of the breasts : Attention should be given the breasts 
preparatory to nursing. As these organs enlarge, the clothing 
must be arranged so as to avoid undue pressure upon them. 
The nipples, if retracted, should be drawn out and gently 
manipulated for a few minutes daily. In the last few weeks 
daily inunctions of the nipples with fresh cocoa-butter or white 
vaseline may be recommended as a prophylactic against fissures 
during nursing. The use of astringent lotions, such as tea, 
brandy, etc., commonly employed, should be proscribed. 

Should vaginal discharge be present, daily injections of boric- 
acid solution at the temperature of the body may be employed, 
the fountain-syringe only being used. 

Sexual intercourse nmst be restricted, and should not be- 
indulged in at the menstrual dates, especially by women who 
have previously aborted. 



56 OBSTETRIC ANATOMY. 

Digestive irregularities should be controlled. The regular 
action of the bowel must be maintained. Woman seems to be 
a naturally constipated organism, and is especially so during 
pregnancy. All violent purgatives should be avoided ; the best 
laxatives are aloin and cascara sagrada. The mineral waters 
prove very useful, such as salines, etc. 

The urinary excretion requires careful attention throughout 
pregnancy. Chemical and microscopical examination of the 
urine should be made every month at first; and in the later 
months every week. The total amount voided in the twenty- 
four hours should be noted. 

The nervous condition of the pregnant woman should always 
be noted. All undue excitement should be avoided, and any 
depression of spirits combated. Plenty of sleep — at least 
eight hours each night — should be obtained. Daily naps should 
be encouraged. 

The use of drugs should be avoided as much as possible dur- 
ing pregnancy. Large doses of quinine and calomel should 
not be administered. The all too common habit of taking 
drugs of the coal-tar series by women, to relieve headache, etc., 
should be especially discouraged during pregnancy, on account 
of their deleterious action on the heart. Many of the cases of 
severe cardiac failure following labor may be set down to this 
pernicious habit. 

The physician should make a careful general examination of 
every pregnant woman under his care about the eighth month 
of the pregnancy. A careful external and, if thought neces- 
sary, an internal examination should be made. The pelvis 
should be measured and the attitude of the foetus noted. The 
breasts and nipples should also be examined. Inquiry should 
also be made as regards the presence or absence of vaginal 
discharge. If present, its character should be noted and a 
bacteriological examination made. 

OBSTETRIC ANATOMY. 

For detailed anatomy of the female pelvic structures the 
student is referred to special works ; or to obstetric systems, 
such as Jewett's " Practice of Obstetrics." 

The chief anatomical elements concerned in labor are three 



THE UTERUS. 57 

in number, namely: (1) the uterus; (2) the pelvi-genital 
canal ; (3) the foetus. 

In the act of parturition the mutual reaction of these ele- 
ments is concerned. 

The uterus may be couceived of as a nuiscular sac opening 
into a curved tube, the upper part of which is bony, therefore 
rigid ; and the lower part yielding, being formed of muscle 
and other soft structures. This curved tube is the pelvi- 
genital canal, which includes the distensible vagina, the upper 
part being intrapelvic, while the lower, in the pelvic floor, is 
subpelvic. 

The fcetus is the passenger, and consists of two ovoids, the 
trunk and the head ; the former plastic, the latter more or less 
rigid, and therefore the more important as regards its relations 
to the birth-canal. 

The Uterus. 

At term the uterus is an ovate viscns; it is less part of the 
birth-canal than it is the engine by which the passenger — the 
foetus — is expelled. 

The cavity of the uterus at term has been stated as measur- 
ing 12 inches in length, 9 inches in breadth, and 8 inches in 
depth. 

The walls of the uterus vary in thickness from one-fourth 
to one-fiftli of an inch ; the posterior being thicker than the 
anterior. 

The muscle-fibres of tlie uterus may be distinguished at 
term as forming rongldy three layers : an outer, a middle, and 
an inner layer : 

In the outer layer there are two sets of fibres : (1) longitudi- 
nal and (2) transverse (Fig. 21). 

The longitudinal fibres, posteriorly from the junction of the 
body with the cervix, pass in the form of a broad band verti- 
cally upward over the fundus and down the middle line ante- 
riorly to the cervix ; the marginal fibres toward the fundus 
branching off to interlace with those of the round and broad 
ligaments. 

The transverse fibres arranged at right angles to these pass 
across the uterus from side to side ; at the fundus passing from 
one cornu to the other. These fibres interlace in great part at 



58 



OBSTETRIC ANATOMY. 



the sides of tlie uterus, but some of them are prolonged along 
the broad and the round ligaments as well as along the tubes. 



Fk;. 21 




External muscular layer of the posterior wall of the uterus. 

In the middle layer the fibres have no definite direction on 
account of the numerous bloodvessels traversing them. They 

Fig. 22. 




Middle muscular layer at the fundus : a, a, superficial layer dissected back ; 
b, branches belonging to the inner layer ; t, t, tubes. 

pass in every direction — longitudinal, transverse, and oblique — 
twisting and curving about the vessels. Frequently they are 



THE UTERUS. 



59 



arranged in the form of a figure-of-eiglit, forming rings about 
the vessels, thus constituting living ligatures (Fig. 22). This 
layer is probably the thickest, and is most marked in the upper 
segment of the uterus. 

In the inner layer some fibres are arranged in a series of con- 
centric rings about the oritices of the tubes (Fig. 23). Other 
fibres pass directly across from 
one cornu to the other trans- ^^'' ^ ' 

versely ; while others pass 
downward longitudinally to 
the cervix, in the middle line 
of the anterior and posterior 
walls. 

Uterine segments : These 
layers are not all distinct, but 
shade imperceptibly into one 
another. In the Hpj:)er part of 
the uterus the arrangement in 
layers is fairly distinct ; but 
in the lower part the fibres are 
more loosely arranged, passing 
chieflv in a lono-itudinal direc- 
tion. 

Hence the uterus may be 
divided into two portions, the upper of which has a firmer 
muscular arrangement than the lower. 

These portions are termed respectively the upper and the 
hirer uterine segrnent><. 

The line of separation between the segments lies nearly at 
the level of the uterovesical fold of the peritoneum, and is 
termed the retraction-ring, or BancWs ring. 

The upper segment plays an active role in labor, while the 
lower has but a passive role. The lower segment along with 
the cervix must undergo dilatation preparatory to the expulsion 
of the f(Tetus. 

The upper segment includes roughly the upper two-thirds 
of the entire body of the uterus; while the lower segment and 
the cervix, which are nearly of equal lengths, forui the remain- 
ing one-third. 

The round and the broad ligaments, which have become 




Internal surface of the uterus as 
shown after incision in the median 
line of the anterior wall. (Parvin.) 



60 OBSTETRIC ANATOMY. 

liypertrophied during j)rogiiaiKy, serve as guys to steady the 
uterus during its contractions, so that its h)ng axis corresponds 
to that of the pelvic inlet. 

The peritoneum covering the uterus is firmly attached to this 
organ as far down as the retraction-ring; below this its attach- 
ment is loose and it may easily be stripped off. Thus the site 
of the retraction-ring, or BandFs ring, is at the lower border 
of firm peritoneal attachment. 

The peritoneum at term has in front of and behind the uterus 
the same relations as in the non-pregnant condition ; but at the 
sides it has been so lifted up by the enlarged uterus that it does 
not descend into the pelvis. The broad ligaments have become 
so elevated that their bases are only at the pelvic brim, extend- 
ing on either side from the iliopectineal eminence to the sacro- 
iliac joint. Thus there exists on either side of the uterus at 
term a large triangular area uncovered by peritoneum. Owing 
to the drawing up of the uterosacral ligaments the pouch of 
Douglas becomes much deeper than in the non-pregnant con- 
dition. 

The Relation of the Full-term Uterus to Contiguous Structures. 

The intestines do not descend behind the uterus at all, and 
in front only as low as the umbilicus. A portion of the rectum 
lies behind the uterus, and occasionally a loop of the sigmoid 
flexure of the colon. 

The urinary bladder lies wholly within the pelvis before the 
onset of labor, its highest point being below the symphysis 
pubis, except when distended. 

The cellular tissue about the uterus exists as a thin layer 
behind ; but in front there is a broad band between the cervix 
and the bladder. At the sides of the uterus it is enormously 
increased as compared with the non-pregnant condition. At 
the bases of the broad ligaments (defined above) there exists 
only cellular tissue (no peritoneum) between the uterus and 
the pelvic; wall ; this deposit extends upward and backward 
between the layers of the broad ligament into the iliac fossae. 

The ureters enter the pelvis just in front of each sacro-iliac 
joint and pass downward, forward, and inward to the neck of 
the bladder in such a way that they are not in the least liable 
to pressure between the uterus and the bony pelvis. 



BONY PELVIS. 61 

The shape and position of the uterus as well as the direction 
of the axis of its cavity change as the organ passes from its 
relaxed state to one of active contraction. These will there- 
fore be discussed later. 

The Pelvi-genital Canal. 

Bony Pelvis. 

Definition : The pelvis is the bony basin, or canal, which 
forms the most important part of the birth-canal (Fig. 24). 

Ftg. 24 




The female pelvis. (Jevvett.) 

The term is derived from the Latin pelvis, a bowl. The pelvic 
canal is irregularly funnel-shaped, flattened from before back- 
ward, the larger end looking upward and forward, the smaller 
downward and baclvward, when the woman is in the erect 
position. It contains in the non-pregnant state the essen- 
tial organs of generation, and in labor the child is expelled 
through it. 



62 OBSTETRIC ANATOMY. 

Au intimate knowledge of the pelvis as related to the 
mechanism of labor is essential to complete understanding of 
the problems of the art of obstetrics. 

General description : The pelvis is composed of the sacrum, 
the coccyx, and the two ossa innominata. Each of these 
bones is made up of separate parts which become united by 
the twentieth year of life. The articulations of the pelvis, 
w'hich are of considerable obstetrical importance, are the sacro- 
iliac joints, the sacrococcygeal joint, and the symphysis pubis. 

The sacro-iliac joints : The opposed surfaces of each bone 
forming these joints are covered with tliin plates of cartilage. 
These become separated by spaces containing a small quantity 
of glairy fluid, but no synovial membrane can be demonstrated. 
Each of these joints has anterior and posterior ligaments and 
intercartilaginous bands ; of these, the posterior are by far the 
most important. Each of these posterior ligaments is formed 
of three fasciculi ; the two superior run nearly horizontally 
from bone to bone; while the inferior passes obliquely down- 
ward and inward from the posterior superior spine of the ilium 
to the third and fourth sacral vertebrae. 

The sacrococcygeal joint has an interosseous fibrocartilage 
which permits recession of the coccyx. Its ligaments are of 
no importance. 

The symphysis pubis : The slightly convex surface of each 
pubic bone is covered with a thin plate of cartilage sufficient 
only to fill out any irregularities in the bones forming the joint. 
The opposed surfaces are held together by an intervening mass 
of fibrocartilage, which constitutes the interpubic disk. A 
small cavity is frequently present in the centre of this disk, 
the result of absorption of the fibrocartilage ; it is non-syn- 
ovial in character. 

The ligaments of this joint are four in number — anterior, 
posterior, superior, and inferior ; of these, the most powerful is 
the inferior, often termed the ligamentum arcuatum. It is a 
strong fibrous bimdle passing across from one descending 
pubic ramus to the other, blending at the median line with the 
interpubic disk. 

Besides the ligaments which are associated with the pelvic 
joints, we have the sacrosciatic ligaments, which play a very 
important part in the mechanism of labor. 



BONY PELVIS. 63 

The greater sacrosciatic ligament arises from the posterior 
inferior spine of the ilium and from the side of the sacrum 
and coccyx. It narrows and thickens in its middle part, be- 
coming broad again at its anterior attachment to the inner sur- 
face of the ischial tuberosity. 

The lesser sacrosciatic ligament takes its origin from the 
side of the sacrum and coccyx, and, passing in front of the 
greater, is inserted into the spine of the ischium. 

Mobility of the pelvic joints : Toward the end of gestation 
there obtains a certain degree of swelling or oedema of all the 
interarticular structures of the pelvic articulations, which per- 
mits of some slight expansion of the pelvis during labor, under 
the wedge-like advance of the foetal head. The sacrum per- 
mits of a slight rotation on its transverse axis. There is also 
a hinge-like motion of the coccyx on the sacrum which permits 
an enlargement of the anteroposterior diameter of the pelvic 
outlet. 

The pelvis presents two divisions, the false and the t7nie pel- 
vis, the dividing-line being at the plane of the brim — i. e., the 
plane cutting the upper end of the sacrum, the top of the sym- 
physis pubis, and the iliopectineal line on either side. 

The false pelvis has but little obstetric interest; it simply 
forms with the vertebral column and the abdominal walls a 
funnel-shaped approach to the true pelvis, and is included in 
the abdominal cavity. 

The true pelvis constitutes that portion of the pelvis lying 
below the iliopectineal lines. It is a deep basin-shaped cavity, the 
posterior wall, formed by the sacrum and coccyx, being sharply 
curved with an anterior concavity. The anterior loall is formed 
by the symphysis pubis and is short and straight. The lateral 
walls, which are formed by the lower portions of the ilia, the 
rami and tuberosities of the ischia, the sacro-iliac ligaments, 
and parts of the descending rami of the pubes, are irregular in 
outline, sloping inward, so that the transverse diameter of the 
pelvis is less at their lower than at their upper extremities. 

The true pelvis may be divided into three portions: 1, the 
inlet, or superior strait ; 2, the outlet, or inferior strait ; 3, the 
excavation, or cavity. 

(1) The inlet, or superior strait, of the pelvis, sometimes termed 
the hinm, is usually described as being heart-shaped, though in 



64 OBSTETRIC ANATOMY. 

the fresh state it is more nearly circular. Its boundaries are 
defined by the top of the sacrum behind, the iliopectineal lines 
on either side and the top of the symphysis pubis in front. 

(2) The outlet, or inferior strait (Fig. 25), is bounded by the 
subpubic ligament, the descending rami of the jmbes, the rami, 
tuberosities, and spines of tlie ischia, the sacrosciatic ligaments, 
and the coccyx. Its outline is roughly triangular in shape, 
but when distended by the advancing head in labor, it becomes 
ovate, owing to the distensibility of the sacrosciatic ligaments 
and the yielding character of the coccyx and sacro-iliac joints. 

Fig. 25. 



Outlet of pelvis. (Lelsehman.) 

(3) The excavation, or cavity of the pelvis, is bounded by 
the superior and inferior straits, and comprises all that i)ortion 
of the pelvis between them. 

Posteriorly^ the cavity is bounded by the sacrum and coccyx ; 
anteriorly, by the pubic bones and their rami ; laterally, by the 
lower portions of the ilia, the bodies, tuberosities, spines, and 
rami of the ischia, and by the sacrosciatic ligaments. 

The posterior wall is concave from above downward ; its 
depth, following the sacral curve, is 11.5 to 12.5 cm. (4J to 5 
inches). 

The anterior ivall is concave from side to side ; its depth at 
the symphysis is 4 cm. (If inches). 

The lateral wall is about 9 cm. (3^ inches) in depth. 



BONY PELVIS. 65 

For description each must be divided into three portions, 
which may be mapped out in Fig. 26. 

The first jmrtion is triangular in shape, its base being aline 
drawn from the iliopectiueal eminence to the top of the sacro- 
iliac joint, its lateral boundaries meeting at the iliac spines. 
This portion is bony throughout, and is smooth and curved. 

The second portion lies forward and somewhat below the 
first, and has but little bone in its composition, being chiefly 
made up of the membranous tissues of the foramen ovale cov- 
ered by the obturator muscle. 

These structures are at term somewhat softened and more 
elastic than in the non-pregnant condition. When the pre- 

FiG. 26. 




Side view of pelvis. 

senting part in labor, in advancing, impinges on these structures 
their recession converts this portion of the lateral wall into 
more or less of a groove, with bony edges and elastic floor ; 
this groove deepens as it descends, and its direction tends toward 
the lower border of the symphysis. The ischiopubic ramus 
forming the lower part of this portion, is curved laterally out- 
ward and lends itself to the continuation of this groove. 

The third portion is made up mainly of the pyriformis 
muscle and the elastic sacrosciatic ligaments ; its borders are 
bony, being composed posteriorly of the lateral borders of the 

5— Obst. 



6^ 



OBSTETRIC ANATOMY. 



sacniin and coccyx, and anteriorly by the posterior edge of the 
ilium. During descent of the head these ligaments and muscles 
are put on the stretch, and this portion is thus converted into 
a K)ng, s|)iral gi'oove, which deepens as it descends and turns 
forward. 

The second and third portions of tlie lateral walls are termed 
respectively the anterior and the posterior lateral grooves of the 
])elvis. 

The question of the role they play, if any, in the mechanism 
of labor will be discussed later. 

Obstetric planes of the pelvis : The pelvic canal varies in size 
and shape at ditiereut parts of its course; these variations are 

Fig. 27. 




Obstetric diameters of the pelvic brim : A A', conjugate diameter; T T', transverse 
diameter ; L O, left oblique diameter ; R O, right oblique diameter. (Jewett.) 



best understood by means of a series of transverse planes 
through the pelvic cavity at diiferent levels. Three of these 
are of special importance obstetrically : the plane of the brim, 
the plane of the outlet, and middle plane of the cavity. 

Plane of the brim : The anatomical brim of the pelvis is at 
the level of the true pelvis, Avhile the ohdetrlcal plane of the 
brim is situated at the level of least expansion of the upper 



BONY PELVIS. 



67 



part of the pelvic canal. This lies at the level of the summit 
of the sacral promontory, the iliopectineal line, and the posterior 
surface of the symphysis pubis, at a point 1 cm. (| of an inch) 
below its upper margin (Fig. 27). 

Plane of the outlet : At the outlet also the anatomical and 
obstetrical planes differ. The obstetrical plane of the outlet 
is defined by the tip of the sacrum, the lower border of the 
ischial spines, and the lower border of the symphysis pubis at 
a point just above the lower margin (Fig. 28). 

Fig. 28. 




Obstetric diameters of the pelvic outlet : S. P., sacropubic diameter; Bi. I., bis- 
Ischial diameter; Bi. S., bisischiatic diameter, (Jewett.) 



Plane of the cavity : The middle plane of the pelvic cavity 
lies at the level of the upper end of the third piece of the 
sacrum, the middle of the symphysis pubis, and the centre of 
the acetabular cavities (Fig. 29). 

Internal pelvic diameters : The dimensions of each plane are 
measured in four directions : the anteroposterior, the transverse, 
and the two oblique. 

At the plane of the brim : The anteroposterior diameter of 
the brim is the least distance between the sacral promontory 
and the symphysis pubis. It is measured from the middle of 



68 



OBSTETRIC ANATOMY. 



the sacral promontory to the posterior surface of the symphy- 
sis, at a point 1 cm. {^ inch) below its upper margin. It is 




Diagram showing axes and planes of pelvis : A B C D, axis of entire parturient 
canal ; X, anus as distended at acme of expulsion ; E F, plane of brim ; K L, mid- 
plane of cavity ; M N, plane of outlet ; P, axis of brim ; Q R, axis of mid-plane ; 
S T, axis of outlet ; // H. horizon ; E N, diagonal conjugate diameter. 

termed the conjugatey or true conjugate ^ and measures 11 cm. 
(4| inches) (Fig. 27). 



BONY PELVIS. 
Fig. 30. 



69 




Planes of the pelvis with horizon : A B, horizon ; C D, vertical line : A B 1, angle 
of inclination of pelvis to horizon, equal to 60° ; B I C, angle of inclination of pelvis 
to spinal column, equaHo 150°; C I J, angle of inclination of sacrum to spinal col- 
umn, equal to 130° ; E F, axis of pelvic inlet ; L M, mid-plane in the middle line; 
N, lowest point of mid-plane of ischium. (Play fair.) 




The inlet, or superior strait. 
A P, anteroposterior diameter, 4.3 to 4.5 inches, or II-IIV2 centimetres. 

TS, transverse, 5.3 " or IS^^ 

R 0, right oblique, 4.7 to 4.9 " or 12-123^ 

X 0, left oblique, 4.7 to 4.9 " or 12-123^ 

The circumference of the inlet is 15.8 inches, or 40 centimetres. 



70 OBSTETRIC ANATOMY. 

The frdnsverse diameter (Fig. 31) is the greatest distance 
between the iliopectineal lines, and measures 13.5 cm. (5 J 
inches). 

The oblique diaineters (Fig. 31) are measiu'ed one from the 
right and the other from the left sacro-iliac joint where it inter- 
sects the iliopectineal line, to the opposite iliopectineal emi- 
nence. The right oblique springs from the right, and the left 
oblique from the left, sacro-iliac joint. They each measure 
about 12.5 cm. (5 inches). 

At the plane of the cavity: The anteroposterior diameter is 
the distance from the upper margin of the third piece of the 
sacrum to a point midway on the posterior surface of the sym- 
physis (Fig. 30), and is 12.5 cm. (5 inches). 

The transverse diameter is the greatest diameter of the pelvis 
at this plane, and measures 12 cm. (4| inches). 

The oblique diameters of this plane are valueless from an 
obstetrical point of view. 

At the plane of the outlet : The anterojjosterior diameter is a 
line drawn from the tip of the sacrum to a point just above the 
lower border of the symphysis pubis (Figs. 28 and 29). It 
measures 11.5 cm. (4|- inches). 

The transverse diameter at this plane may be measured in 
two places (Fig. 28). The greatest transverse diameter is the 
bisischial line, which is measured from a point on the inner 
surface of one ischial tuberosity at the middle of its posterior 
border, to the same point on the opposite side. This measures 
11.5 cm. (4J inches). 

The least transverse diameter is the distance between the 
ischial spines, the bisischiatic diameter, which measures 10.5 
cm. (4| inches). 

The oblique diameters at this plane are of no importance. 

It will be noted by comparing the dimensions at the differ- 
ent planes, that the transverse diameter of the pelvic canal 
grows progressively smaller from the brim to the outlet ; the 
difference between these being 2.5 cm. (1 inch); and also 
that the anteroposterior diameter of the pelvic canal is 0.5 
longer at the outlet than at the brim. 

Measurements : The internal diameters of the bony pelvis 
as stated in the following table are sufficiently accurate for all 
practical purposes, and should be memorized: 



THE SOFT PARTS OF THE PELVIC CANAL. 71 

Anteroposterior. Oblique. Transverse. 

Brim, 10 cm. (4 inches). 11.5 cm. (4.^ inclie«). 12.5 cm. (5 inches). 

Cavity, 11.5 " (4^ " ) 11.5 " (4^ " ) 11.5 '' (4J " ) 

Outlet, 12.5 " (5 " ) 11.5 " (4J " ) 10.0 '' (4 " ) 

Inclination of the pelvis : The inclination (Fig. 30) of the 
plane of the pelvic brim to the horizon, with the woman in the 
erect position, may be stated as fifty-five degrees. The inclina- 
tion of the pelvis, of course, differs with changes of posture. 
In the erect position the symphysis i)ubis is nearly 9 cm. (3 J 
inches) below the level of the promontory ; and the coccyx is 
2 cm. (f inch) above the level of the lower border of the 
symphysis pubis, the pubococcygeal line making an angle of 
ten degrees with the horizon. 

The Soft Parts of the Pelvic Canal. 

The lower segment of the uterus and the cervix form a part 
of the birth-canal ; while the upper segment is the chief source 
of the propelling power. This portion of the soft parts has 
already been described. 

The soft parts which line the bony pelvis and those which 
contribute to the formation of the pelvio floor are of great ob- 
stetric importance. The former diminish somewhat the diame- 
ters of the bony ca\'ity ; the latter form the knver portion of 
the birth-canal. 

The psoas and iliacus muscles, which lie at the brim, dimin- 
ish the transverse diameter of this portion of the pelvis a 
quarter of an inch on either side, thus bringing this diameter 
down to about the size of the oblique diameter. 

The external iliac vessels run along the inner borders of 
these muscles, and the main trunk of the lumbar plexus fol- 
lows the course of the psoas, the crural nerve running between 
the psoas and iliacus muscles. 

The obturator internus, which is but a thin muscle-sheet, 
covers portions of the anterior and lateral walls and a part of 
the small sciatic notch. Thus it practically covers the anterior 
inclined groove of the pelvis, and is by many thought to make 
the groove of but little value obstetrically. 

The pyriformis, which is a thin fan-shaped muscle, lies a 
little over the edge of the sacrum and completely fills the great 



72 OnSTKTRlC ANATOMY. 

sciatic notch, thus eoutributiiig to the formation of the floor 
of the so-called posterior pelvic groove. 

The anterior wall of the pelvis is not covered by muscle, 
but during pregnancy the bladder lies in relation with it. 
During labor the greater part of this viscus is drawn up above 
the inlet ; but its base may, in tedious labors, be subjected to 
prolonged pressure between the head and the pubes, thus 
damaging it to such an extent that sloughiug may occur and 
vesicovaginal fistula result. 

The rectum lies in front of the left sacro-iliac joint. It runs 
forward and inward, descending in the median line down the 
anterior surface of the sacrum and coccyx. When distended 
it may encroach on the pelvic space to a very considerable 
extent. Its presence in this portion of the pelvis is supposed 
to account for the greater frequency with which the long 
diameter of the foetal head occupies the right oblique diameter 
at the onset of labor. 

The pelvic floor comprises the soft structures which close the 
outlet of the bony pelvis. Its function is to support the 
pelvic viscera. Its upper limit is the peritoneum, its lower, 
the skin ; it is perforated by the rectum, vagina, and urethra. 

Hart has divided the pelvic floor into two segments, as 
follows: the posterior vaginal wall and the soft structures 
behind it constitute the sacral segment; the anterior vaginal 
wall and the soft structures in front of it compose the pubic 
segment. 

In labor the pubic segment is drawn upward and the sacral 
segment is pushed downward and distended as the foetus 
descends. The resiliency of the sacral segment holds the foetal 
mass in close relation with the ischiopubic rami during the 
latter part of labor, and assists in its final expulsion. 

The pelvic floor when stretched by the foetus measures, 
from the tip of the sacrum to the anterior border of the 
pubic segment, about 5 inches (12.75 cm.). It is mainly com- 
posed of muscles and fasciae. 

The muscles forming the pelvic floor are the levator ani, the 
sphincter ani, the transverse muscles of the perineum, and the 
sphincter vaginae. 

The levator ani muscle, which is the most important, takes 
its origin from the posterior layer of the triangular ligament, 



THE SOFT PARTS OF THE PELVIC CANAL. 



73 



from the spine of tlie iscliiiim, and from the whole lengtli of 
the " white line " (Fig. 32). 

Those fibres which arise from the pubes pass backward to 
be inserted into tlie last two pieces of the coccyx, and on 



Fig. 32. 




Drawing from a photograph of a dissection made at the Long Island College 
Hospital : 1, symphysis : 2, coccyx ; 3, anus ; 4, superficial fibres from the pubic 
origin of the levator ani ; 5, deeper fibres from the pubic origin ; 6, fibres from the 
"white line"; 7, fibres from the spine of the ischium ; 8, gluteus maximus muscle. 
(Browning.) 



their way send fibres to the urethra," vagina, and the internal 
sphincter ani, and a few to unite with those of the opposite 



74 



OBSTETRIC ANATOMY. 



side behind the anus. That part arising from the "white 
line " and the rest of the line of origin which forms the greater 
bulk of the muscle, runs backward, downward, and inward 
to the side of the coccyx and lower end of the sacrum. The 
muscle thus forms a diaphragm with the concavity upward. 



1 



Fig. 33. 




Coronal section of the pelvis: ^, ilium; P, ischium; C, acetabulum ; D, psoas 
magnus muscle ; E, obturator internus ; F, levator ani ; G, sphincter ani externus ; 
a, transversalis fascia ; h, iliac fascia ; c, obturator fascia ; d, " white line " ; e, recto- 
vesical fascia ; /, Alcock's canal. (Browning.) 

The other muscles entering into the formation of the pelvic 
floor form a second layer thinner than that formed by the 
levator ani. They all meet at the central point of the peri- 
neum. 

The fascia forming the pelvic floor is probably a more 



THE SOFT PARTS OF THE PELVIC CANAL. 



75 



important element obstetrically than tlie muscle layer. It 
mav be described in two portions, a parietal and a visceral 
layer (Fig. 33). 

Tile parietal layer, which is the less important, covers the 
muscles, padding the sides of the pelvis ; in front it forms the 
j)osterior layer of the triangular ligament, and is perforated by 
the urethra and vagina ; at the back it helps to cover the 
sciatic notches. 

The visceral layer is continuous Avith the fascia covering the 
sides of the pelvis. From its line of origin at the "white line" 
the visceral layer passes downward and inward to the middle 
line, where its fibres fuse with the connective tissue at the base 
of the bladder, the vagina, and the rectum, thus slinging these 
structures in the pelvis. On its lower surface is the levator 
ani muscle. 

The perineum may be defined as that })ortion of the body 
lying between the anus and the orifice of the vagina. It is 
formed by the perineal body (Fig. 34), which is the aggrega- 



FiG. 34. 




The external genital?, as seen in mesial section: a, anus; h, perineal body; c, 
ina ; d, urethra; e, labium minus; /, clitoris; g, fossa navicularis, in front of 



vas: 

which is the hymen 



(Henle.) 



tion of the tissues lying between the rectum and vagina below 
their point of contact. On section the perineal body is tri- 
angular in outline and pyramidal in form. Its skin surface 
(base) from the anterior part of the anus to the posterior part 
of the vaginal orifice measures about 2.5 cm. (1 inch). 



76 



OBSTETRIC ANATOMY. 



The parturient axis : The 
vie canal is a line which 




Axis of the birth-canal : r, anus; a b, 
plane of outlet of completed canal; e, 
perpendicular to plane or axis of ex- 
pulsion. 



mathematical axis of the pel- 
pierces each pelvic plane per- 
pendicularly at its central 
point. This axis is a curved 
line with its concavity for- 
ward, and represents very 
closely the course the foetal 
head follows in its descent 
through the pelvis in normal 
labor (Fig. 35). 

The axis of the brim if pro- 
longed would strike the tip 
of the coccyx below, above 
it would touch a point on 
the abdomen near the umbil- 
icus. 

The axis of the bony outlet, 
if prolonged upward, would 
pass immediately in front of 
the sacral promontory. The 
axis of the plane of the vulvo- 
vaginal inng at the moment 
when the head is expelled, is 
a line directed upward almost 
parallel with the lower part 
of the abdominal wall of the 
mother (Fig. 29). 

Hirst points out that the 
direction of the pelvic canal 
depends entirely on the curve 
of the sacrum, and that this 
differs in every pelvis. 



The Foetus. 

The third anatomical element concerned in labor is the body 
to be expelled. This consists of the whole ovum, viz., pla- 
centa, membranes, and foetus. The anatomy of the placenta 
and membranes has already been described, therefore this 
section will be concerned with the foetus only. 



THE FCETUS. 77 

The mature foetus : At term the foetus measures usually 
between 46 and 51cm. (18-20 inches) in length, lis iveight 
averages from 3150 to 3290 grammes (7-7^- pounds), males 
being somewhat heavier than females. Not rarely the weight 
may reach as high as 5400 grammes (12 pounds), the phe- 
nomenal W'cight of 9000 grammes (20 pounds) has been 
recorded. 

The head bears a much larger proportion to the trunk than 
in the adult. Its diameters are greater than those of any part 
of the trunk, and are more incompressible. It therefore offers 
the principal resistance to the passage of the child through 
the pelvis. In the mechanism of labor it is with the head 
that obstetric problems are mainly concerned. 

The whole body of the foetus before and during labor forms 
a roughly ovoid mass. So long as the long diameter of the 
foetal ovoid coincides as nearly as possible with the axis of 
the parturient canal the mechanism is a normal one. This is 
the case whichever extremity, head or breech, the foetus 
presents. 

The head : Obstetrically, the foetal head presents tw^o divi- 
sions : (1) the cranial vault; (2) the cranial base and face. 

The vault, which is compressible, is composed of thin, raem- 
brano-cartilaginous plates, which are in themselves flexible 
and are, with the exception of the frontal bone, united to the 
base and to each other by membrane only. 

The base is formed of bones which are solid and firmly 
ankylosed. It is therefore incompressible, thus affording 
protection during birth to the ganglia at the base of the 
brain. 

The attachment between the base and the vault of the 
cranium is along a line drawn through the junction of the 
orbital and "squamous " parts of the frontal bone, continued 
backward by the squamous suture and downward by the 
hinge-like junction of the tabular part of the occipital bone 
to the basilar and condylar portion. 

The bones forming the cranial vault are the two parietal, 
the frontal, and the " squamous '^ portions of the occipital 
and of the two temporal bones. These are united only by 
the unossified external periosteum and by the dura mater. 
The plasticity of the vault is due to the cartilaginous char- 



78 



OBSTETRIC ANATOMY. 



actor of the bones and to the existence of the membranous 
interspaces. 

The sutures of the vault are the membranous intervals 
between two adjacent bones. The most important are the 
sagittal, running between the two parietals; the frontal, 
between the two portions of the frontal bone ; the coronal, 
between the frontal and parietals ; and the lamhdoidal, between 
the parietals and the occipital bone (Figs. 36 and 37). 

Fig. 37. 





Anterior and posterior fontanelles, sagittal, lambdoidal, coronal, and frontal 

sutures. 



The fontanelles are the larger spaces formed by the widen- 
ing out of the sutures between the angles of three or four 
adjacent bones. 

The largest is the anterior fontanelle, or bregma, situated at 
the junction of the sagittal, the coronal, and the frontal sut- 
ures. It is kite-shaped, or quadrangular, with its most acute 
angle forward. Its average diameter is about one inch, but 
its size varies in different heads. Four lines of sutures run 
into it. 

The posterior, or small, fontanelle is formed at the junction 
of the sagittal and lambdoidal sutures, and is merely felt as a 
small triangular depression. There are three lines of sutures 
running into it. 

Tetiiporal fontanelles : At the junction of the temporal with 



TEE FCETUS. 

Fig. 38. 



79 




The diameters of the fcetal head: O F, occipitofrontal; O B, suboccipito- 
bregmatic; B T, cervicobregmatic. The maximum diameter, occipitomental, is 
indicated by the long dotted arrow. Measurements are centimetres. (l<arabeut 
and Yarnier.) 




diameters of the flexed head: P P, Biparietal diameter, 9^4 cm. (After 
Farabeuf and Yarnier.) 



80 OBSTETRIC ANATOMY. 

the parietal and occipital bones, on either side of the head, 
there exists a small quadrilateral fontanelle. 

False fontanelles are occasionally observed either in the 
body of the bone or in the course of a suture. These are 
due to some defect in ossification. A quadrilateral false fon- 

FiG. 40. ' 




Vertex. Left occipito-anterior position. (Ribemont-Dessaignes and Lepage.) 

tanelle is not infrequently to be felt in the line of the sagit- 
tal "uture a short distance from the usual small fontanelle. 

Obstetric landmarks: Certain landmarks about the foetal 
head are of considerable obstetrical importance. 

The vertex is that portion of the head between the anterior 



THE FCETUS. 81 

and posterior fontanelles, and extending laterally to the parie- 
tal eminences. 

The occijjut is that portion of the head behind the posterior 
fontanelle. 

The sinciput is that portion of the head in front of the 
bregma. 

Fig. 41. 




Vertex. Right occipito-anterior position. (Ribemont-Dessaignes and Lepage.) 

The glabella is the space over the root of the nose and 
between the supra-orbital ridges. 

Five protuheranceH are presented by the cranial bones : 
The occipital protuberance situated in the middle of the 
squamous portion of the occi})ital bone about 2.5 cm. (1 inch) 
behind the po.sterior fontanelle. The parietal protuberance 
is the boss or eminence in the centre of each parietal bone. 
6— Obst. 



82 OBSTETRIC ANATOMY. 

The frontal protuberance is the eminence in the centre of 
each frontal bone. 

Diameters of the foetal head : Occipitofrontal, extending 
from the glabella to the tip of the occipital protnberance ; 
11.5 cm. (41 inches) ; posterior end, Fig. 88, too high. 

Fig. 42. 




Vertex. Right occipito-posterior position. (Ribemont-Dessaignes and Lepage.) 

Occipitomental y extending from the ti]) of the occipital pro- 
tuberance to the centre of the chin. Measures 14 cm. (5^ 
inches). The posterior end. Fig. 38, is too high. 

Suhoccipitobreginatic, extending from the junction of the 
neck and occiput to the centre of the bregma. Measures 9.5 
cm. (3J inches). 

Suboccij)itofrontal, extending from the junction of the neck 



% 



THE FCETUS. 83 

and occiput to the summit of the brow. Measures 11 cm. 
(4| inches). 

Biparietal, measures through the centre of the parietal 
eminences. Measures 9.5 cm. (3|- inches). 

Frontomental, extending from the summit of the brow to 
the centre of the lower border of the chin. Measures 9 cm. 
(34 inches). 
^ ^ ^ Fig. 43. 




Vertex. Left occipito-posterior position. (Ribemont-Dessaignes and Lepage.) 

Cervlcobreginatic, extending from the junction of the neck 
and chin to the centre of the bregma. Measures 9.5 cm. (3J 
inches). 

The above diameters (Figs. 38 and 39) are all of them 
more or less compressible. 

The remainder are incompressible. 

Bimastoidj measured through the mastoid processes, 7 cm. 
(2f inches). 



84 



OBSTETRIC ANATOMY. 



Bimalary measured through the malar eminences, 7 cm. (2f 
inches). 

Bitemporal, measured through the lower extremities of the 
coronal suture, 8 cm. (3 J inches). 

The following table is sufficiently accurate for all practical 
purposes and should be memorized : 

Fig. 44. 




Face. Left mento-anterior position. (Farabeuf and Varnier.) 

Diameters of the Foetal Head (Jeicett). 
Biparietal, 9 cm. (J^ inches 



Suboccipitobregmatic, 


9 cm. (31 


a 


Frontomental, 


9 cm. (31 


u 


Occipitofrontal, 


11.5 cm. (41 


i( 


Occipitomental, 


14 cm. (51 


(i 



THE FCETUS. 85 

In the following table the circumferences of the most im- 
portant planes of the foetal head are given : 

Circumferences of the Planes of the Fcetal Head. 

Suboccipitobregmatic, 33 cm. (13 inches). 

Suboccipitofrontal, 35 cm. (]3| " ). 

Occipitofrontal, 34.5 cm. (13J '' ). 

Fig. 45. 



Face. Right mento-anterior position. (Farabeuf and Varuier.) 

Importance of flexion of foetal head : When the head is com- 
pletely flexed, as it is in normal labor, its smallest plane 
(measured by its circumference) comes into relation with the 
different pelvic planes successively as the head descends. This 



86 



OBSTETRIC ANATOMY. 



smallest plane, as will be noticed in the above tal)le, is the suh~ 
occipitobregmatic. The importance of the maintenance of 
complete iflexion of the fcrtal head until almost the moment 
of its delivery will thus be easily comprehended. 



Fig. 46. 



1 




^ht mento-posterior position. (Farabeuf and Varnier.) 



Moulding of the foetal head : During labor the head under- 
goes more or less compression which results in its alteration 
in shape. 

Moulding results from the overlapping of the cranial bones, 
\vhich takes place in a definite way in all cases. The parietal 



THE FCETUS. 



.87 



boues override the occipital and frontal bones ; and of the 
parietals the one most pressed upon, generally the one in rela- 
tion to the promontory, always slips under the other. The 



Fig. 47 




Face. Left mento-posterior position. (Farabeuf and Varnier.) 

two halves of the frontal bone follow the same rule as the 
parietal bones. 

The whole volume of the head is reduced by compression, 
the greater portion of the cerebrospinal fluid and of the con- 
tents of the cerebral bloodvessels being forced out of the 
cranial cavity during labor. 



88 



OBSTETRIC ANATOMY. 



The foetal tnmk : The diameters of importance in the trunk 
are few, as the whole body is very incompressible. The h'ls- 
acromial is the longest and measures 12 cm. (4| inches), and is 
reducible to the extent of 2 to 3 cm. 

The hitrochanteric measures about 10 cm. (4 inches). 

The dorsosternal measures 9 cm. (3^ inches). 




Breech Left saero-anterior position. (Farabeuf and Varnier.) 



The length of the foetal ovoid, that is, from the vertex to the 
breech, may be given as 24-24,5 cm. (9^ to 10 inches). 

Mobility of the foetal head and trunk : The movements of 
flexion, extension, and rotation of the/cc/a/ head are of great 
importance in the mechanism of labor. Flexion is limited by 
the pressure of the chin upon the chest. 



THE FCETUS. 



89 



Extension is limited by compression of the occiput against 
the back. Rotation is safe through an arc of 90 degrees 
on each side^ till the chin points over the shoulder. 

The trunh permits of a certain amount of rotation which is 
limited by the rotation of the vertebral bodies. A certam 



Fig. 49. 




Breech. Right sacro-anterior position. (Farabeuf and Varnier.) 

degree of lateral flexion is also possible as well as ordinary 
flexion and ex'.ension. 

The posture of the foetus is the relation which the trunk, 
head, and limbs of the child have to one another, independently 
of the relations of any part of the foetus to any part of the 
mother. 

The normal posture of the foetus during pregnancy and 



90 



OBSTETR TC A NA TOM 1 '. 



parturition is one of flexion, the head being flexed on the 
trunk, tlie tliighs on the abdomen, and the legs on the thighs, 
the arms behig folded on the chest. 

The relation of the uterine and foetal axes : During the latter 
part of pregnancy and in parturition the long axis of the foetal 
ovoid may correspond to the long axis of the uterus (longi- 
tudinal) ; or may be at right angles to it (transverse). 




Breech. Right sacro-posterior position. (Farabeuf and Varnier.) 



Normally the long axes correspond ; any deviation from this 
relationship leads to serious complications in labor. 

Commonly, obstetricians apply the term presentation to 
denote the relation of the long axis of the foetal ovoid to the 
uterine axis. In our opinion the use of this term to denote 



THE FCETUS. 



91 



this relationship is a misnomer. The term jjresentation should 
only be used to denote the part of the foetus which presents at 
the pelvic brim and is accessible to the examining iinger. 

Presentations: Under the definition just given there are 
three forms of fcetal presentation : the ceplialicy thejpe/t'ic, and 

Fig. 51. 




Breech. Left sacro-posterior position. (Farabeuf and Varnier.) 

the somatic. There occur distinct varieties of each of these 
forms, as will be noted in the following table ; 

Table of Foetal Presentations. 

Frequency. 

97 per cent.— («) vertex, (h) face, (c) brow. 
1.6 per cent. — («) breech, (^) leg, (c) foot. 



Cephalic J 

Pelvic, 

Somatic, 



0.5 per cent. — (a) shoulder, (6) elbow, (c) hand. 



92 



OBSTETRIC ANATOMY. 



The latter form of [)resentation is often termed transverse or 
crossed birth. 

Position: The pelvic brim is divided by the conjugate and 
transverse diameters into Jour quadrants. Position may be 
defined as the relationship of the presenting part of the foetus 
to the quadrants of the pelvic brim. Thus for each presenta- 

FiG. 52. 



I 




Shoulder. Left scapulo-anterior position. (Farabeuf and Varnier.) 

tion there are four positions. They are named according to 
the ])articular quadrant confronted by the presenting part. 

In vertex, face, and breech presentations the long diameter 
of the presenting part engages in one of the oblique diameters 
of the pelvic inlet. 

In vertex presentations >vhen the occiput confronts the left 



THE FCETUS. 93 

anterior quadrant of the pelvic brim, the position is left 
occipito-anterior, and so on. 

Face i^resentations are named similarly according to the 
direction of the chin, left mento-anterior, etc. 

Breech presentations are named according to the position of 
the sacrum, left sacro-anterior, etc. 




Shoulder. Right scapulo-anterior position. (Farabeuf and Varnier.) 

Shoulder presentations are named according to the direction 
of the scapula, left scapulo-anterior, etc. 

The positions are sometimes spoken of as first, second, third, 
or fourth, the left anterior being the first and the others fol- 
lowing in order from left to right around the pelvic brim. 
This method is apt to mislead, as various authorities differ as 
to which is the first position in certain presentations, and con- 



94 OBSTETRIC ANATOMY. 

fusion results. It is better to designate each position in full 
or by the initial letters (Figs. 40-55). 

Fig. 54. 




Shoulder. Right scapulo-postcrior position. (Farabeuf aud Varnier.) 

Vertex positions : 

Left occipito-anterior, L. O. A. 
Right occipito-anterior, Iv. O. A. 
Right occipitoposterior, R. O. P. 
Left occipitoposterior, L. O. P. 

Face positions : 

Left nicnto-anterior, L. M. A. 
Right men to-anterior, R. M. A. 
Right mentoposterior, R. ]\I. P. 
Left mentoposterior, L. M. P. 



THE FCETUS. 



95 



Breech positions : 

Left sacro-anterior, L. S. A. 
Right sacro-anterior, R, 8. A. 
Eight sacroposterior, R. 8. P. 
Left sacroposterior, L. S. P. 

Somatic or shoulder presentations : 
Left scapulo-anterior, L. Sc. A. 
Right scapulo- anterior, R. Sc. A. 
Right scapuloposterior, R. Sc. P. 
Left scapuloposterior, L. Sc. P. 




Shoulder. Left seapulo-posterior position. (Farabeuf and Varnier.) 

Face presentations are sometimes named according to the 
pelvic quadrant confronted by the brow, as left fronto-anterior, 
L. F. A., etc. 



96 THE MECHANISM AND COURSE OF NORMAL LABOR. 

That some form of cephalic presentation occurs in 97 per 
cent, of all cases is not quite satisfactorily accounted for. 
There are three conditions each of which has some influence 
in bringing about this result. These are: 1, the position of 
the centre of gravity of the foetus ; 2, the relative shapes of 
the uterus and of the foetus ; 3, the movements of the foetus : 

1. Matthews Duncan long ago found that the centre of 
gravity of the foetus lay somewhere about the shoulders, and 
nearer the right than the left, owing to the presence of the 
liver on the right side. Thus if a foetus is immersed in a 
saline fluid of the same specific gravity as its own, it sinks 
into a position with the back of its right shoulder looking 
downward, this, therefore, becoming the lowest part of the 
body. 

2. The relative shapes of the uterus and of the foetus : The 
fundus is at term the most roomy part of the uterus ; hence 
at term the more bulky breech finds greater accommodation in 
the upper segment, Avhile the head readily adapts itself to the 
smaller lower segment. 

The foetal movements : The movements of the legs of the 
foetus are probably more powerful than those of the arms. 
Hence if the child lie with the feet downward these will 
when in a state of motion come into contact with the resist- 
ing pelvic brim, which will result in lateral displacement of 
the child's body. The shape of the uterus will then tend to 
convert this attitude again into a longitudinal one. The 
action of the specific gravity of the foetus will tend to bring 
the cephalic pole downward, and when once this position lias 
been obtained its alteration is not likely to occur provided no 
abnormal conditions are present. 

THE MECHANISM AND COURSE OF NORMAL 
LABOR. 

Definition : The term eutocia, indicating normal labor, is 
applied to labors which terminate without artificial aid and 
without injury to the mother or child. 

Under this definition, in this work, only iincomplicated 
vertex preseniatioiis will be classed as normal. 

At this point it may be mentioned that a woman pregnant 



I 



THE CAUSES OF THE ONSET OF LABOR. 97 

for the first time is termed a primigrmrida ; one in labor or in 
the puerperium for the first time, a primij^ara. 

If a woman has had several children or miscarriages pre- 
viously she is termed a multipara. When it is desired to in- 
dicate the exact number of the labor she is spoken of as a 
i para, ii para, iii para, and so on. 

Stages of labor : While there is frequently a premonitory 
stage before labor actually sets in, it is customary to divide 
labor itself into three distinct stages : 

The first stage, or stage of dilatation, ends with the full 
dilatation of the os uteri, with which the rupture of the 
membranes is usually coincident. 

The second stage, or stage of expulsion, ends with the 
complete birth of the child. 

The thM stage, or placental stage, ends with complete 
expulsion of the placenta and membranes and retraction of 
the uterus. 

The duration of normal labor : The average duration of 
normal labor in primipara3 may be stated as eighteen hours ; 
while in multiparse it is from eight to ten hours. 

The average duration of the first stage in primiparse is 
about twelve hours ; in multiparse from six to eight hours. 

The second stage in primiparse lasts about four to six 
hours; and in multiparse from one to two hours. 

The thir^d stage, which is but rarely terminated spontane- 
ously, lasts from a few minutes to two hours. 

The Causes of the Onset of Labor. 

No entirely satisfactory theory has been advanced to ac- 
count for the onset of labor, which usually occurs on the two 
hundred and eightieth day after the beginning of the last 
menstrual period. 

It is known that three motor centres exist which preside 
over uterine contractions ; a centre in the medulla ; the cervi- 
cal ganglia ; and the ganglia in the anterior vaginal wall and 
the uterine walls. 

Labor is not the result of the operation of one, but rather 
of a number of concurrent causes. These act by increasing 
the painless rhythmic contractions of tlie uterus present 
throughout the whole period of pregnancy. 
7_0bst. 



98 THE MECHANISM AND COURSE OF NORMAL LABOR. 

The following are among the most probable causes : 

1. Loosening attachment of the ovum, thus converting it 
into a foreign body ; 

2. Excess of carbon dioxide in the blood ; 

3. Distention of the uterus by the ovum ; 

4. iNIental impressions. 

1. Loosening attachment of the ovum: It has been observed 
that toward the end of pregnancy the trabeculse in the spongy 
layer of the decidua vera decrease in size, causing this layer, 
as it were, to shrivel up, and thus easy separation of the ovum 
is permitted. Also slight hemorrhages, which occur as the 
result of violent uterine contractions, tend to aid in detaching 
the ovum from the uterine walls. The ovum thus becomes a 
foreign body and excites the uterus to further action. 

2. Excess of carbon dioxide in the blood: As the foetus 
develops it demands more nourishment, and there is at the 
same time an increase in its tissue-waste, which includes 
carbon dioxide. This gas has been proved by Brown-Sequard 
to excite uterine action by stimulating the nerve-centres men- 
tioned above. 

Certain changes are supposed to take place in the placenta 
leading to an increase in the quantity of carbon dioxide. 
When the venous blood has accumulated a sufficient quantity 
of this gas, uterine contractions are stimulated to such an 
extent that labor is established. 

3. Distention of the uterus: All hollow viscera wdien dis- 
tended to a certain limit contract and expel their contents. 
Witness the distention of the bladder, the rectum, and the 
overloaded stomach of the infant. 

4. Mental impressions : The emotions play a large part fre- 
quently in inducing uterine contractions. Great grief, joy, or 
severe fright experienced toward the end of pregnancy fre- 
quently precipitate labor. 

The Forces of Labor. 

The expcllent forces of labor are : 

1. Contractions of the uterus and of the vaginal and pel- 
vic muscles ; 

2. Contractions of the abdominal muscles and diaphragm ; 

3. Gravity. 



I 



CONTRACTIONS OF THE UTERUS, ETC. 99 

1. Contractions of the Uterus and of the Vaginal and Pelvic 

Muscles. 

Uterine Contractions. 

These are by far the most important factor in bringing 
about the expulsion of the ovum. 

The contractions are involuntary, occurring independently 
of the woman's will ; though they undoubtedly are weakened 
or even inhibited by various agents. Emotion, such as the 
dread of pain, or nervousness caused by the entrance of the 
physician or a stranger, may inhibit them. A loaded rectum 
or a full bladder may reflexly inhibit uterine contractions. 

They are peristaltic, the wave of the contraction being from 
the fundus to the cervix, and lasting from one-third to two- 
thirds the length of the labor pain. 

They are intermittent. The contraction begins gradually, 
rapidly reaches an acme, and then slowly passes off. This 
may be demonstrated clinically by keeping the hand on the 
woman's abdominal wall throughout a contraction ; the uterus 
will be felt to harden gradually ; then, remaining in this con- 
dition for a short interval, to relax and become soft again. 

Their duration averages about one minute. In the earliest 
stage of labor they occupy but a few" seconds ; but in the ex- 
pulsive stage they last longer and are stronger. The con- 
tractions are rhythmical in their intermissions. There is a 
certain regularity in their appearance and disappearance. The 
greater their frequency the longer their duration. At the 
beginning of labor the interval is long, say a quarter of an 
hour ; toward the end the interval between the pains may be 
but a few seconds, so that the contractions seem to be almost 
continuous. 

The contractions are painful, hence the term '^ pains" 
usually applied to them. This pain is due to the forcible 
stretching of the cervix and its attachments, and of the vagina 
and vulva consecutively ; also in part to the fact that the 
uterus is contracting against resistance. A parallel to this 
latter occurs in the intestine when an obstruction exists. The 
pain is usually referred to the sacral region, especially in the 
earlier stages ; later, when the sacral nerves are pressed upon 
by the advance of the foetus, the pain is felt down the limbs. 



L.cfC. 



100 THE MECHANISM AND COURSE OF NORMAL LABOR. 

The individual muscle-fibres of the uterus during contraction 
become shorter and thicker than they are during relaxation. 

Retraction is a process peculiar probably to all involuntary 
muscle-fibres ; but is most marked in those of the uterus. 
Retraction enables a muscle-fibre which has shortened dur- 
ing contraction to relax without returning to its original 
length. The fibres after contraction do not quite return to 
their original length, but remain persistently somewhat shorter 
and thicker. 

Retraction is due in part also to a rearrangement of the 
fibres. These are assumed at the beginning of labor to be 
nearly end to end ; in the course of retraction they come to 
lie almost side to side. Retraction is practically limited during 
labor to the muscle-fibres forming the upper uterine segment. 
This portion of the uterine wall as the ovum is pushed down 
becomes gradually thicker ; thus its propulsive force during 
contraction augments^ and it is enabled to remain constantly 
in contact with the upper end of the ovum until its expulsion 
from this segment. 

The lower uterine segment, not possessing the power of retrac- 
tion, becomes progressively thinner and dilates as the ovum is 
forced down through it. Retraction thus enables the uterus 
to preserve the expulsive results of contraction. 

Polarity is a useful term to express the fact that throughout 
labor the expelling part of the uterus — the upper segment — is 
in a state of opposite function to the sphincter part — the 
lower segment and cervix. 

During pregnancy the muscle forming the body of the 
uterus is practically at rest, while the cervix, especially the 
internal os, is in a state of tonic contraction, it is active. 
During labor this relation is inverted, the body contracts 
while the cervix is relaxed. This relation is taken advantage 
of when it is necessary to induce labor for any cause — that is, 
to set up active contractions in the muscle forming the body 
of the uterus. This is usually accomplished by dilating the 
cervix either manually or by instruments, which brings about 
the desired result. 

Effect of uterine contractions: In changing the shape and 
position of the uterus: During a contraction the longitudinal 
and anteroposterior diameters of the uterus are increased. 




CONTRACTION OF THE ABDOMINAL MUSCLES, ETC 101 

while its transverse diameter is decreased, the whole organ 
assuming a roughly cylindrical form (see also pp. 38 and 39). 
The fundus is held against the abdominal wall and becomes 
more prominent ; this brings the long axis of the uterus into 
line with that of the inlet of the pelvis. 

0)1 the circulation in the uterus and placenta : During con- 
traction the uterine sinuses are slowly obliterated and emptied, 
refilling as it passes off; but the foetal portion of the placenta 
is not affected. Thus throughout the whole of pregnancy the 
circulation of blood in the uterus is assisted by the regular 
rhythmical uterine contractions. 

"On thefwtal heart: The foetal heart is slowed because the 
pressure on the placental site raises the general foetal blood- 
pressure. 

On the maternal pulse : The maternal pulse-rate increases 
ten to twenty beats, thus contrasting with the foetal pulse- 
rate. 

Vaginal and Pelvic 3Iuscles. 

These muscles play but a very unimportant part in bring- 
ing about the expulsion of the ovum. They act only in the 
later stages. 

2. Contraction of the Abdominal Muscles and Diaphragm. 

The muscles entering into the formation of the abdominal 
walls, along with the diaphragm, when simultaneously in a 
state of contraction, increase the intra-abdominal pressure and 
thus render very important aid to the uterus. These muscles 
taken altogether form, as it Avere, a second layer of muscular 
tissue external to the uterus. 

Their mode of action is as follows : A deep inspiration is 
taken, thus flattening out and depressing the diaphragm, 
which is then fixed by the closure of the glottis ; then the 
muscles in the abdominal walls contract. The descent of the 
diaphragm pushes the fundus forward ; this is resisted by 
the contraction of the muscles of the abdominal wall, so that 
the resultant of the combined pressure of these muscles is in 
the direction of the long axis of the uterus — that is, down- 
ward in the axis of the pelv^ic brim. 



102 THE MECHANISM AND COURSE OF NORMAL LABOR. 

The action of these muscles is not exerted until the second 
or expulsive stage, and is at first entirely voluntary. In the 
later stages of the expulsive period their action is entirely 
involuntary. 

At first they act only during the acme of a i)ain, when the 
woman voluntarily bears down ; but later, when the pain 
lasts longer, the woman is compelled to open the glottis to 
respire, thus relaxing the pressure ; but immediately another 
breath is taken, they act again, so that there are often several 
abdominal contractions to one pain. 

3. Gravity. 

The weight of the child and of the waters contained in 
the membranes exerts but a small influence in aiding ex- 
pulsion, except perhaps during the first stage of labor, when 
the woman is more or less in the erect or semirecumbent 
position. 

LABOR— FIRST STAGE. 

Premonitory Signs and Symptoms of Labor. 

The events which indicate the approach of labor are varia- 
ble in their duration and may be so slight as quite to escape 
observation. 

The change of position of the uterus which takes place 
during the last weeks of pregnancy has been referred to 
already. 

Irregular pains, usually felt low down in the abdomen in 
front, are frequently complained of by patients for some days 
before the onset of true labor. They are sometimes severe, 
and may cause much suffering to sensitive women. These 
"false pains,'' as they are termed, may be distinguished 
from true pains by their irregularity and by their site ; true 
labor-pains being felt chiefly in the sacral region. These 
false pains have absolutely no effect on the cervix, and no in- 
crease in the vaginal secretion accompanies them. 

Frequency of micturition and, less often, of defecation, may 
be troublesome during the last few days, and are probably 
caused by increase in the nervous excitability of the pelvic 
structures usually present at this time. 



I 



MECHANISM OF THE FIRST STAGE. 103 

Characteristic Signs and Symptoms of the Onset of Labor. 

Regular uterine contractions : The interval between these is 
long at first, bnt shortens steadily as the labor progresses. 
The pains at this period are always referred to the sacral 
region. 

Appearance of the " show " : This is the term commonly 
applied to the mucus tinged w^ith blood which escapes from 
the cervix and vagina at this time. The mucus comes 
chiefly from the cervix, and the blood from the separated 
surfaces of the membranes and the uterine walls just above 
the internal os. 

Softening and shortening of the cervix : These changes can 
only be noticed by making a vaginal examination. The 
softening of the cervix is due to infiltration Avith serous exu- 
date resulting from the interference with the return circula- 
tion caused by the uterine contractions. The shortening of 
the cervix results from the yielding of the internal os, which 
is undoubtedly a physiological relaxation analogous to that 
which takes place in sphincter muscles. 

Mechanism of the First Stage. 

The uterine contractions during this stage are occupied en- 
tirely with dilating the cervix, there being little or no expulsion 
of the ovum, this being limited to the slight advance of the 
bag of membranes through the internal os. 

Dilatation of the cervix results from: (1) the yielding of 
the internal os, w^iich is a physiological relaxation ; (2) the 
hydrostatic pressure of the bag of waters ; and (3) the action 
of the long muscular fibres in the outer muscle-layer of the 
uterus. 

1. The first of these has already been discussed. 

2. The hydrostatic pressure of the bag of waters : The first 
result of uterine contraction is an increase in the geneixd intra- 
uterine fluid pressure. When the waters are abundant and 
the membranes intact the effect of this pressure is nil so far 
as the foetus is concerned, as the law^ of fluid pressure is that 
it is equal and opposite in all directions. 

The direction of the force of the uterine contraction is 
centripetal; this is opposed centrifugally by the bag of waters. 



104 THE MECHANISM AND COURSE OF NORMAL LABOR. 

The force of the contraction is centripetal, while the force 
exerted by the bag of waters in opposition is centrifugal. 

These two forces would then equalize one another if: (1) 
the uterine wall were of equal thickness throughout, and 
therefore of ecpial strength throughout ; and if (2) the uterine 
wall were in a state of e(][ual contraction throughout at the 
same moment of time. 

Both these conditions fail in that : first, the uterine wall is 
not of equal thickness throughout, the lower segment being 
thinner ; and having a solution in its continuity (the yielding 
internal os), it is weaker and therefore must expand ; secondly, 
the uterine wall is not in a state of equal contraction through- 
out at the same moment of time, in that the contraction is 
vermicular, beginning at the fundus and spreading downward 
to the cervix, so that when the fundus is in a state of con- 
traction the cervix is relaxed. This may be demonstrated 
clinically by keeping the finger-tip on the lowest point of the 
bag of waters, when at the onset of a pain this will be felt to 
become tense some seconds before the woman complains of 
the pain which causes the increase of pressure. 

For these reasons the force of the centrifugal pressure of 
the waters is exerted most markedly on the lower uterine 
segment and cervix ; hence dilatation of these parts takes place 
as a result of the increase in the general intra-uterine fluid 
pressure. 

^.s' dilatation proceeds the membranes, having become 
loosened from their attachment to the uterine walls, insinuate 
themselves into the opening. Since the fluid within the mem- 
branes transmits the force of the uterine contraction equally in 
all directions, the bag of waters is distended laterally as well 
as downward, thus exerting an expansive action directly on the 
walls of the cervix, and finally on the margins of the external 
OS. As the cervix and external os dilate this lateral pressure 
of the bag of waters increases proportionately. 

3. The action of the longitudinal muscle-fibres of the uterus : 
The contents of the uterus being practically incompressible, 
the pull of the longitudinal fibres will result in drawing the 
lower uterine segment and cervix, whose structure is thinner 
than that of the upper segment, up over the contained body. 
In this action the oblique fibres assist to a considerable extent. 



MECHASJSM OF THE FIRST STAGE. 105 

The wave of contraction probably passes through the longi- 
tudinal fibres more rapidly than through the circular fibres, 
hence the former will tend to draw the cervix up over the 
presenting part while the lower segment is relaxed. 

When the cervix and external os have become well dilated 
the membranes usually rupture. This, as a rule, occurs during 
a pain, and is announced by a gush of Avaters from the vagina. 
The quantity escaping will depend on how rapidly the pre- 
senting part of the foetus descends and occludes the lower 
uterine segment. 

The rupture of the membranes may occur at or before the 
onset of labor ; or may not take place till the end of the 
expulsive stage ; but it is very rare that a full-term child is 
born with the membranes unruptured ; though it has hap- 
pened that in precipitate labors the whole ovum has come 
away entire. 

On the rupture of the bag of waters, the presenting part of 
the foetus takes its place as a dilator. The fluid still retained 
in utero then transmits the effective intra-uterine pressure to 
that portion of the foetus in contact with the margins of the os. 

In dry labors — /. e., in cases where the membranes rupture 
prematurely, thus permitting the escape of the waters before 
dilatation has progressed to any extent — the first stage of labor 
becomes tedious, for the reason that no part of the foetus can 
act as a dilator so satisfactorily as the hydrostatic pressure 
exerted by the bag of waters. In these cases the long fibres 
of the uterus practically draw the cervix up over the wedge- 
like presenting part of the foetus, whatever that part may be. 

These longitudinal fibres when in a state of contraction 
produce a downward traction of the fundus upon the foetus 
tending to force it downward ; this force is transmitted to the 
presenting part, in vertex or in breech cases, by the vertebral 
column of the child. 

This downward traction of the fundus exerted by the longi- 
tudinal fibres when in a state of contraction, does not cause a 
drawing down, or descent, of the fundus uteri, because the 
circular fibres by their more powerful action tend, as it were, 
to straighten out the somewhat bowed foetus ; with the result 
that the position of the fundus in relation to the abdominal 



106 THE MECHANISM AND COURSE OF NORMAL LABOR. 

Avail throughout labor does not vary ; but the whole resultant 
of the forces exerted by the contractions of these two sets of 
fibres is transmitted down the vertebral column of the foetus to 
the presenting part, which is thus forced to advance, while 
at the same time the cervix is dilated and drawn up over it. 

Os uteri during first stage of labor : On making a vaginal 
examination very early in labor, in a primipara, that portion 
of the cervix not yet taken up may be felt as a soft appendage 
to the spherical surface of the distended lower pole of the 
uterus. Possibly the external os may be sufficiently soft and 
dilated to permit the insertion of the finger-tip. Under the 
same circumstances in a multipara the os may be quite patent 
long before the cervix is taken up, so that the finger may 
easily be inserted into the uterus. Under these circumstances 
the only way to be certain of the extent of cervix still remain- 
ing to be taken up is to insert the finger till the membranes 
can be felt, then, while withdrawing it making firm pressure 
on the posterior wall, note the length of cervix before the mar- 
gin of the external os is reached. 

Later, when the cervix is completely taken up, during a 
pain the sharp edges of the external os can be distinguished, 
and the smooth surface of the membranes can be felt stretch- 
ing across the aperture. 

In primipara the edge of the external os is at first thin and 
sharp ; later it becomes more cedematous. In multipara it 
may be thick, and as a result of laceration in a previous 
labor the external os may have a very irregular shape. 

The degree of dilatation may be described by stating that 
the OS will admit one, two, or three fingers ; or it may be com- 
pared with the size of a ten-cent piece, quarter, etc. 

Clinical Phenomena of the First Stage. 

The initial labor-pains come on, as a rule, in the earlier part 
of the night ; and they differ but little from the false pains, 
except that they occur more regularly and gradually increase 
in strength and frequency. 

The pains are sharp and nagging, many patients finding 
them more difficult to bear than those of the expulsive stage. 
Many prefer to walk restlessly about, bending over a chair 



MECHAMSM OF THE SECOND STAGE. 107 

or the foot of the bed during the acme of the pain. Usually 
a plaintive cry or moan is uttered with each pain, and the 
patient's face becomes congested owing to involuntary fixation 
of the respiratory muscles. 

Reflex vomiting is of frequent occurrence as dilatation pro- 
gresses. 

The patient is compelled frequently to evacuate the bladder 
and rectum on account of the increased nervous irritability of 
the organs. 

The pulse and respiration are not markedly affected, as a 
rule, in tliis stage, though in cases where it is prolonged the 
rate of both may be considerably accelerated ; and the tem^^ 
perature may rise to 100° F., or even higher. 

Anatomy of the Soft Parts at the End of the First Stage. 

The external os is, as a rule, dilated so as to admit three 
fingers. The cervix is completely taken up. The whole lower 
segment of the uterus is thinned out somewhat from stretch- 
ing ; while the upper segment is slightly thicker than before 
the onset of labor. 

The bladder, as a rule, is drawn upward with the cervix, the 
upper end being displaced forward over the pubes. The 
upper end of the vagina is somewhat distended. 



LABOR— SECOND STAGE. 

Mechanism of the Second Stage. 

During this stage the foetus is expelled from the maternal 
passages. 

Vertex presentations being considered in this work as nor- 
mal, and the left occipito-anterior position being by far the 
most common, the corresponding mechanism will be fully 
described at this point ; while the mechanism of the other 
positions will be described only in so far as they differ from it. 

The mechanism of this stage is concerned chiefly with the 
movements which the foetal head and trunk undergo in their 
passage through the birth-canal. 



108 THE MECHANISM AND COURSE OF NORMAL LABOR. 

Tlio most important part of the meclianism is that relating 
to the ItcdcJ, on account of its size and the incompressibility 
of its diameters as compared with the trunk. 



The Head Movements. 

These are : descent ; flexion ; internal rotation ; extension ; 
and finally, after expulsion, restitution or external rotation. 

Descent : Descent of the head begins, as already mentioned, 
with the rupture of the membranes, or as soon as it comes into 
complete contact with the lower uterine segment, or os. It is 
caused by the uterine contractions reinforced by the action of 
the abdominal muscles and diaphragm, and persists through- 
out this stage, resulting in the other movements about to be 
described. 

Flexion : The position of the head is naturally one of par- 
tial flexion, as it lies in the lower uterine segment at the onset 
of the second stage. As the head descends this flexion in- 
creases as the result of various causes: 

(a) At the beginning of this stage the intra-uterine fluid 
pressure acts on the whole base of the skull, and flexion re- 
sults from the different angles at which the anterior and pos- 
terior slopes of the vertex meet the resistance of the lower 
uterine walls. The friction offered by the wall to the anterior 
end of the head is greater and this end is more impeded in its 
descent, hence flexion is assisted. This is reinforced by the 
action of the circular fibres of the cervix compressing the 
head. The force exerted by these fibres not being equal and 
()p})osite, flexion of the head is favored. 

(/>) When the waters drain away sufficiently to permit the 
fundus to come into direct contact with the foetus, then a 
more powerful force is exerted to produce flexion of the 
head. The propulsive force of the uterine action trans- 
mitted down the vertebral column of the foetus acts on the 
head along a line running nearer the occipital than the sin- 
cipital pole. 

The head is so attached to the trunk that its sincipital is 
longer than its occipital pole ; it corresponds to a lever with 
unequal arms, the occipito-atlantoid articulation being the 



MECHANISM OF THE SECOND STAGE. 



1U9 



pivotal point, and the sincipital the long arm of the lever. 
Hence the sincipital pole is more acted on by the resistance 
offered to descent, while the occipital pole receives the 
maxmnm pressure from above (Fig. 56.) 

Thus is flexion produced 
and maintained. Fig. 56. 

The advantage of flexion is 
that it brings the smallest, or 
suboccipito-bregmatic, circum- 
ference of the head into rela- 
tion Avith the girdle of resist- 
ance offered by the pelvis and 
soft parts. It also results in 
the occiput reaching the pelvic 
floor in advance of any other 
part of the head, a point of 
very considerable importance, 
as will be seen later. 

When flexion is complete the 
posterior fontanelle is brought 
wdthin easy reach of the ex- 
amining finger. At this time 
if the sagittal suture be felt, it 
seems to lie nearer to the pos- 
terior than to the anterior 
w^all of the pelvis, and the 
head seems to occupy a some- 
w^hat oblique position in the 
pelvis as regards the plane of 
the brim, the anterior or right 
parietal bone seeming to be at 
a lower level than is the left 
parietal bone. This led Naegele 
to infer that the head usually 
entered the pelvis with the sagittal suture nearer to the prom- 
ontory than to the pubes. This is not a real but an appar- 
ent obliquity, and is due to the pelvic inclination. The head 
normally enters the pelvis Avith its horizontal plane in com- 
plete coincidence with the plane of the brim. This condition 
is known as syncUtism. The absence of the proper relation of 




Illustrating the different lengths of 
the frontal arm, F B, and the occipital 
arm, B O, of the lever presented by the 
foetal head. (Jewett.) 



no THE MECHANISM AND COURSE OF NORMAL LABOR. 

these planes is known as ast/nclitism, a condition which 
usually occurs when any deformity of the pelvis is present. 
Internal rotation : The long diameter of the foetal head 
occupies the right oblique diameter of the brim when the 
position is L. O. A., but it must emerge at the outlet with its 
long diameter directed anteroposteriorly, because this diameter 
of the outlet is the greater. The movement by which the 

Fig. 57. 




Beginning extension of head. (Farabeuf and Varnier.) 



oblique position at the brim is converted into an anteropos- 
terior position at the outlet is termed rotation. 

Without good flexion of the foetal head rotation cannot 
occur. As a result of flexion the occipital pole of the foetal 
head occupies a lower plane in the pelvis than does the sin- 
cipital pole. When the occiput is directed forward the sin- 
ciput must move in a contrary direction — that is, backward. 
When the head descends in the L. O. A. position, the occiput 
must of necessity enter the upper part of the anterior groove 
on the left side of the pelvis. It will follow this groove in 
its descent, and will thus come into contact with the pelvic 



I 



MECHANISM OF THE SECOND STAGE. 



Ill 



floor well forward of the transverse line of the pelvis. As a 
result of this slightly forward direction of the occipital pole 
the sincipital pole will descend along the sacro-iliac groove on 
the right side of the pelvis. When the pelvic floor is reached 
the line of least resistance is downward and forward, hence 
whichever part of the foetal head (in this case the occiput) 
comes into relationship with the pelvic floor first, follows this 
and is directed to the under border of the symphysis 



inie 



pubis. In R. O. P. and L. O. P. positions the occiput de- 



FiG. 58. 




Maximum distention of pelvic floor. Equator of head about to pass. 

and Varnier.) 



(Farabeuf 



scends along one or other, as the case may be, of i\\Q posterior 
grooves of the pelvis, and impinges on the pelvic floor behind 
the transverse line of the pelvic outlet. Potation thus is 
longer, being through three-eighths of a circle instead of one- 
eighth, as in anterior positions. 

Thus the main factor in causing rotation of the head is the 
resistance offered by the pelvic floor. By the time the peri- 
neum is well distended rotation is completed and a portion of 



112 THE MECHANISM AND COURSE OF NORMAL LABOR. 



the liairy scalp over the occiput is in view between the dis- 
tended hibia. 

Extension : At the moment when the next movement, exten- 
sion, begins, the sagittal suture is directed anteroposteriorly 
and the sinciput lies in the hollow of the sacrum. Descent 
goes on in this position until the occiput clears the lower 
border of the subpubic ligament, and the neck is pressed 
firmly against the back of the symphysis. 

The base of the occiput then pivots on the lower edge of 
the symphysis, and at each pain the head extends, stretching 

Fig. 59. 




Occiput rides up in front of symphysis. Pelvic floor retracts. (Farabeuf and 

Variiier.) 

the perineum and vulvar ring as it does so. Gradually the 
vertex, brow, and face successively glide from under the peri- 
neum, which retracts over the chin and the head is born 
(Figs. 57-59). 

Restitution or external rotation : Directly after the head is 
born it resumes its usual relation to the shoulders, namely, 
with its occipitomentjd diameter at a right -angle to the bis- 
acromial. 

The shoulders enter the brim in the opposite oblique to 



CLINICAL PHENOMENA OF THE SECOND STAGE. 113 

the head ; thus in L. O. A. position they enter in tlie left 
oblique diameter, and as they descend the right shoulder 
comes to the front. Hence the head when it escapes from 
the vulva turns so that the occiput points to the left side of 
the mother, which is the same position it occupied at the 
brim. This movement of the head is termed restitution, and 
is of interest, as it indicates usually its primary position 
(Fig. 60). 

Fig. 60. 




Foetal head after restitution. Shows also caput succedaneum. (Ribemont- 
Dessaignes and Lepage.) 

Delivery of the Trunk. 

The anterior shoulder is, as a rule, arrested at the lower 
border of the symphysis, so that the posterior passes over the 
perineum and appears at the vulva first. After the posterior 
shoulder escapes the anterior descends and is delivered. The 
hips emerge with the bisiliac diameter in the anteroposterior 
position. 

Clinical Phenomena of the Second Stage. 

At the conclusion of the first stage the pains not infre- 
quently cease for a time, and the more or less exhausted 

8— Obst. 



114 THE MECHANISM AND COURSE OF NORMAL LABOR. 

woman has a few moments of rest and possibly of sleep. 
Especially is this the case if chloral has been administered. 

The pains are more severe during the second stage and 
last longer ; but the patient becomes more hopeful as a rule, 
for she realizes that with each pain definite progress is being 
made. When the pelvic floor is reached the perineum 
begins to distend from the pressure of the head, and the 
sphincter ani relaxes, so that not infrequently a quantity of 
fascal matter or mucus escapes from the anus. 

At this time the contractions of the abdominal muscles are 
involuntary, and the patient is forced to strain down with 
each pain, holding her breath as she does so. As a rule, the 
woman grasps any support near by firmly with her hands 
and braces her feet, to assist her expulsive efforts. 

In the intervals between the pains she rests quietly and 
may fall asleep. 

AVhen the vulvar ring is being distended the sufferings of 
the woman may become so intense as to result in a condition 
bordering on delirium. At this period the head advances 
rapidly with each pain, coming plainly into view as it does 
so. In the intervals it recedes, thus permitting the circula- 
tion of blood in the perineum to be resumed. 

If this recession does not take place, oedema of the parts 
rapidly comes on, and may be very marked in some cases. 

Usually there is a pause when the head is born. 

Accompanying the delivery of the body there is a gush of 
waters and blood. 

After the birth of the child the woman soon quiets down, 
no matter how noisy she may have been ; the freedom from 
pain affording her great satisfaction and a keen sense of rest. 
Her temperature at this time may be slightly elevated ; 
especially if the labor has been difficult. The pulse-rate 
rapidly subsides and in a few moments resumes its normal 
frequency. 

Moulding of the Foetal Head. 

The child's head, even in normal labor, undergoes considerable 
alteration in shape as it is forced through the maternal passages. 

The manner in which the bones overlap has been already 
referred to. 



ANATOMY OF THE SECOND STAGE. 115 

The degree of moulding depends on the relative size of the 
head and the pelvis, and also upon the extent of ossification 
present. 

The moulding of the head is essential to the mechanism of 
the expulsive stage in that it leads to adaptation of the head 
to the pelvis; and also because its elongation favors rotation 
by increasing the dip of the leading pole, so that it is more 
easily directed forward. 

Elongation : In L. O. A. and L. O. P. positions the elonga- 
tion of the head is along a line joining the chin to the posterior 
upper angle of the right parietal bone. 

In E,. O. A. and R. O. P. positions the elongation of the 
head is along a line joining the chin to the posterior upper 
angle of the left parietal bone. 

This deformity is accentuated by the caput succedaneum. 

Caput Succedaneum. 

Definition : The caput succedaneum is an oederaatous swell- 
ing which is developed on the presenting part in the course of 
birth, usually after rupture of the membranes. The vessels 
of the presenting part become engorged during the pains, and 
serous exudation takes place into that portion of the foetal 
surface which escapes the pressure of the girdle of resistance. 

Its size varies with the degree of force producing it ; hence 
it is large in difficult and prolonged labors. Its size is an 
indication of the degree of obstruction encountered by the 
foetus in its passage through the pelvis. 

Its location indicates the position in which the head has 
descended. In anterior positions it is situated on the posterior, 
and in the posterior positions on the anterior aspect of the 
summit of the head. In left positions it is on the right ; and 
in right positions it is on the left of the median line. 

The exact position of the caput may be modified if the 
head has been subjected to prolonged pressure at the outlet or 
at the vulva. 

Anatomy of the Second Stage. 

When the head is in the distended perineum the shoulders 
lie just within the dilated cervix. 



116 THE MECHANISM AND COURSE OF NORMAL LABOR. 

The uterus has retracted on that part of the foetus remain- 
ing inside it. The differentiation between its upper and lower 
segments has become marked ; and if the labor is a difficult 
one, the retraction-ring may be felt running obliquely across 
the uterus a short distance above the pubes. The higher this 
ring is felt the more serious is the obstruction which has been 
encountered by the foetus. 

The bladder is now wholly above the pubes and the urethra 
is greatly elongated ; hence catheterization is difficult and 
urination impossible, the pressure of the head increasing the 
difficulty. 

The structures in the sacral segment of the pelvic floor have 
been pushed downward and backward ; the contents of the 
rectum are forced out by the pressure of the head ; and the 
anus has become widely distended, permitting the anterior 
wall of the rectum to come into view. The edges of the vulva 
are forced apart and they may be oedematous. 



LABOR— THIRD STAGE. 

This stage of labor is occupied with the detachment and 
expulsion of the placenta and the membranes. 

Mechanism of the Third Stage. 

Separation of the Placenta. 

The placenta is separated by retraction and contraction of 
the uterus. 

Many theories have been advanced to explain the method 
of placental separation ; and the following description is but 
a summary of those most generally accepted. 

As a residt of retraction of the uterus after expulsion of 
the child the placenta is compressed to about one-half its 
original size before detachment occurs. 

The method of its detachment d(!pends on its site. 

If the site be confined to the Avail and does not encroach 
on the fundus, the separation probably begins at the margins 
and advances toward the centre. If the ])lacental attachment 
is to any extent fundal, the placenta, as the result of uterine 



MECHANISM OF THE THIRD STAGE. 117 

retraction, becomes bent over at an angle, and detachment 
will begin at its lower margin and detrusion will occur. That 
is, the placenta will slip down sideways as detachment goes 
on, being detached ]\y the expulsive force of the uterine con- 
tractions. 

As separation advances uterine vessels are torn across and 
some hemorrhage takes place. 

In some cases this retroplacental hemorrhage plays an im- 
portant role in placental detachment ; and in all cases it renders 
easier the shrinkage of the placental site away from the 
placenta. 

Separation of the Membranes. 

As a result of the protrusion of the " bag of membranes '' 
through the os, in the first stage of labor, some separation of 
the membranes from the walls of the lower uterine segment 
takes place. 

Affcer rupture of the membranes and escape of the waters 
the non-elastic membranes become thrown into folds and 
Avrinkles, and as a result become partially detached in some 
places. The placenta, in the process of expulsion, strips the 
membranes completely off the uterine walls as it descends. 

It is important that the amnion and the chorion remain 
firmly united : failure of these structures to adhere to one 
another results in portions of the chorion being left behind 
in the uterus, a condition it is desirable to avoid. 

In cases where too early rupture of the membranes occurs, 
there is no '^ bag of waters," hence the membranes adhere to 
the uterine wall too closely, and no detachment of these can 
occur until the placenta in its expulsion strips them off. 

Expulsion of the Placenta and Membranes. 

As the result of uterine contractions, the placenta is ex- 
pelled. 

It usually presents at the vulva by some spot on its foetal 
aspect about two inches from its lower margin. The presenta- 
tion of the foetal aspect is caused by the retroplacental hemor- 
rhage leading to an inversion of the ])lacenta, which has to strip 
from the uterine wall a portion of the membranes between its 



118 THE MECHANISM AND COURSE OF NORMAL LABOR. 



Fig. 61. 



lower margin and the os ; hence this part is delayed to a certain 
extent (Fig. Gl). The higher in the uterus the placenta is situ- 
ated the more membrane has to 
be stripped off between its lower 
margin and the os, and the greater 
is the degree of inversion, or 
folding over of the placenta. 
The placenta never presents by 
its margin at the vulva unless its 
lower edge was originally situated 
close to the internal os. 

The membranes are dragged out 
by the descent of the placenta ; 
hence they are usually inverted 
and the amnion appears outer- 
most. 

The whole mass of placenta 
and membranes is accompanied 
by a variable amount of clots 
and fluid blood, these coming 
from the placental site. 

After expulsion of the after- 
birth the uterus is found re- 
tracted and contracted to about 
the size of the foetal head. Its 
size varies with the amount of retraction and with the size 
of the child. 

The position of the fundus immediately after labor is about 
half-way between the pubes and umbilicus. Later, when the 
])aralyzed lower segment has regained its tone by retraction, 
the fundus rises to a position about the level of the um- 
bilicus. 

Labor is now completed, and the puerperal period begins. 




Inversion of the ovum and expul- 
sion of the placenta as an inverted 
umbrella. (Schultze.) 



Blood lost in labor: The average amount of blood lost 
in labor is about six to ten ounces. The total quantity 
varies considerably. Women who menstruate profusely 
habitually lose more than those whose menstruation is usually 
scanty. 



OBSTETRIC ANTISEPSIS. 119 



THE MANAGEMENT OF NORMAL LABOR. 

In the management of a case of labor it is the duty of the 
physician to assist the woman in the processes of labor when 
required, in order that she may be spared unnecessary suffer- 
ing and discomfort ; and also to protect her from any infec- 
tion which might be imported from without. 

It has already been mentioned that it is desirable in every 
case to make a preliminary examination of the patient about 
four weeks before the expected confinement. Besides the ordi- 
nary obstetric examination, the general condition of the patient 
should be noted at this time. Any irregularities should be 
corrected, and everything should be arranged so that at the 
date of the expected labor the patient's strength and vitality 
shall be the best possible. 



OBSTETRIC ANTISEPSIS. 

In 1847 Ignatius P. Semmelweis, having been deeply im- 
pressed by the heavy mortality in the A^ienna Maternity, first 
applied the antiseptic method to the management of labor. By 
simply compelling students attending all cases of labor to 
cleanse the hands thoroughly in chlorine-water, he reduced 
the mortality in the maternity clinic from 12 per cent, to 
under 2 per cent, in less than a year. 

Since that date the mortality from puerperal sepsis in all 
maternity hospitals has been reduced to considerably under 1 
per cent. 

That the application of the antiseptic method to the man- 
agement of private labor cases has not been as widespread is 
evidenced by the fact that the mortality-returns, both in Brit- 
ain and America, show there has been but little decrease in 
the number of deaths due to puerperal sepsis in recent 
years. 

The great numbers of women who throng the gynecologic 
clinics in all parts of the country, suffering from disease dat- 
ing from a previous confinement, are witnesses to the fact 
that the application of the antiseptic method to the conduct 
of labor is still far from being as general as it should be. 



120 THE MANAGEMENT OF NORMAL LABOR. 

Antiseptic Agents. 

Soap and hot water are probably the most valuable agents. 
Many who practise obstetrics neglect these, while making 
use of some antiseptic chug in solution, which blinds them to 
the fact that asepsis is more important than antisepsis. 

The plentiful use of soap and hot water accompanied by 
muscle and common sense would greatly reduce not only 
mortality, but also morbidity in obstetric work, even if anti- 
septics had never been heard of. 

The use of these agents should always precede the employ- 
ment of antiseptics. 

Heat, either dry or moist, is the most general and available 
germicide. 

All utensils employed about a puerperal woman should be 
at least scalded thoroughly with hot water, and where possi- 
ble should be boiled. 

All dressings or material which it is intended to use as 
vulvar pads should be boiled or steamed before labor, and 
kept carefully wrapped up until used. 

All instruments should be boiled for at least five minutes 
in a 1 per cent, soda solution, after which they may be placed 
in sterilized water. 

All water used in the labor-room should be boiled, and 
then kept covered until wanted. 

In fact, cleanliness in all that pertains to the woman, not 
only during labor, but for two weeks subsequently, is abso- 
lutely necessary if it is desired to have fever-free obstetric 
cases. 

In all details the method followed should be as simple as 
possible. 

Chemical Antiseptics. 

The most useful chemical germicides are mercuric chloride ; 
carholic acid; and formalin. 

Creolin, lysol, and permanganate of potassium are also 
very commonly employed in obstetric practice. 

It should be remembered that soap decomposes mercuric 
chloride and permanganate of potassium, rendering them inert ; 
that carbolic acid and permanganate of potassium are incom- 



THE OBSTETRICIAN. 121 

patible ; that mercuric chloride is decomposed in the pres- 
ence of albumin, forming therewith an inert albuminate of 
mercury. 

Therefore when the latter is used in a solution for douching, 
it should be combined with tartaric, acetic, or hydrochloric 
acid in the proportion of five parts of the acid to one of 
the mercurial. 

Convenience and accuracy are secured by using tablets 
containing raercuriG chloride combined with the proper pro- 
portion of the acid. Sublimate solutions are used in strengths 
of from 1 : 5000 to 1 : 500. 

Formalin solutions are now replacing sublimate solutions 
for douching purposes, as they are free from the objections 
connected with the use of the latter. Formalin solutions 
vary in strength from 1 : 2000 to 1 : 500 as ordinarily used. 
The strength of the usual commercial formalin is 40 per cent, 
of the gaseous compound formaldehyde in water. 

In the application of the antiseptic method to the conduct 
of labor not only are the obstetrician and the 7iurse con- 
cerned, but also the patient. 

The Obstetrician. 

The obstetrician should always be careful to keep his hands 
not only clean, but also in good condition. He should avoid 
as far as possible any work which w^ill render his hands rough 
and hard. Care should be taken to keep the skin intact, for 
cuts, scratches, and chapping all render the making of the 
hands surgically clean an impossibility. Should there be 
any of these conditions present, it is the duty of the obstet- 
rician to v.ear aseptic rubber gloves when conducting a case 
of labor. Care should be taken not to handle septic material; 
if compelled to do so, the hands should be sterilized repeatedly 
subsequently. 

The nails should receive particular attention. They should 
be cut short and well filed, so that ragged edges may not be 
left to scratch or injure in the slightest degree the maternal 
soft parts. 

There are two methods of sterilizing the hands, both of 
which are probably equally efficacious. These may be desig- 



122 THE MANAGEMENT OF NORMAL LABOR 

nated respectively (1) the sublimate method; (2) the perman- 
ganate method. 

The Sublimate Method. 

(a) The hands and forearms are scrubbed thoroughly for 
five minutes with a nail-brush, using water as hot as can be 
borne and a good soap ; either an ethereal or alcoholic solu- 
tion of green soap being the best for this purpose. Special 
attention must be paid to the nails and subungual spaces. 

(b) After thorough rinsing in plain sterilized water, the 
nails should be cleansed with a nail-cleaner or sterilized mani- 
cure-stick. 

(c) Then the hands and forearms are laved with pure alcohol, 
to dehydrate the skin, for at least one minute. 

(f/) The next step is to immerse the parts in a hot 1 : 2000 
solution of mercuric chloride for from three to five minutes. 

The Permanganate Method. 

The hands and forearms are scrubbed and cleaned as in 
steps a and b of the preceding method. 

(c) They are then immersed for five minutes in a hot satu- 
rated solution of potassium permanganate, vigorous friction 
being applied by means of a sterilized swab, till the skin is 
stained a rich mahogany-brown. 

(d) Then they are bathed in a hot saturated solution of 
oxalic acid till the brown stain has been completely removed. 
This may be followed by rinsing in plain sterilized warm 
water or a 1 : 1000 sublimate solution. 

It is much to be desired that the obstetrician should follow 
the operating surgeon's example not only in the preparation 
of his hands, but in wearing a freshly laundried, or, better, 
sterilized, long coat-gown of linen or duck, when attending a 
case of labor. 

The Nurse. 

The nurse should be no less particular in her attention to 
detail, in the application of the antiseptic method to the con- 
duct of labor. 



THE PATIENT. 123 

The nurse should make an entire change of clothing, after 
taking a bath, before assuming charge of a patient in labor. 
Her clothing should be absolutely clean, and she should wear 
wash-dresses. 

If she has recently been exposed to sepsis, it is her duty to 
inform the physician of the fact before taking charge of a 
case of labor. 

Before attending to the vulva of the patient the nurse 
should sterilize her hands thoroughly, and the process should 
be repeated each time she has occasion to cleanse the parts. 



The Patient. 

The aseptic preparation of the patient should begin weeks 
before the expected date of labor. She should be informed 
of the importance of ^ivmi personal cleanliness. Any diseased 
conditions of the rectum, vulva, or bladder should receive 
treatment. 

At the onset of labor the patient should take a warm bath 
and then put on clean linen. The lower bowel should be 
emptied by an enema. 

' The nurse should then thoroughly scrub the lower part of 
the abdomen and thighs with green soap and hot water, 
making use of a soft hand-brush, or a jute swab, for this pur- 
pose. 

The vulvar hair should be clipped if it be too long. 

Then these parts should be washed with a warm solution 
(1 : 500) of formalin or of (1 : 2000) mercuric chloride. 

After the parts have been dried Avith an aseptic towel a 
sterile vulvar pad should be applied. The pad should be worn 
during the first and second stages of labor. 

The normal vaginal secretion of a pregnant woman has been 
proved to be germicidal ; therefore in normal cases no ante- 
partum vaginal injections should be permitted. Not only is 
vaginal irrigation useless, but it may cause actual harm in im- 
pairing the secretive activity of the vaginal walls, thus inter- 
fering with nature's protection against sepsis. 



124 THE MANAGEMENT OF NORMAL LABOR. 



PREPARATIONS FOR LABOR. 

On the Part of the Physician. 

The physician should give the patient a list of those things 
he wishes her to provide and have ready for the labor. 

The patient, if a priraipara, should be warned of certain 
conditions which may arise at the onset of labor, such as prem- 
ature rupture of membranes, hemorrhage, etc., and instructed 
to send for the physician early. 

The call to a case of labor should always receive the phy- 
sician's immediate attention, such a summons taking prece- 
dence over everything. 

He should go 'provided with such instruments and drugs as 
are likely to be needed in the conduct of ordinary labor and 
in the more important obstetric emergencies. These can all 
be carried in a hand-bag. 

The obstetric bag should contain the following : 

A pair of obstetric forceps. 

Two pair of haemostatic forceps. 

One needle-forceps for suturing. 

Needles, curved and straight, of various sizes. 

A pair of scissors. 

A Sims speculum. 

A pair of long uterine dressing-forceps. 

A double tenaculum. 

A pelvimeter, and a measuring-tape. 

A hypodermic case, well equipped. 

A gravity syringe for douching, etc. 

A long uterine douche nozzle, either of glass or metal. 

Two soft-rubber catheters, Nos. 8 to 12. 

Catgut, silk, and silkworm-gut for suturing. 

Two nail-brushes. 

A small package of sterile iodoform gauze. 

A two-ounce bottle of chloroform. 

A quarter-pound tin of ether. 

A two-ounce bottle of syrup of chloral. 

Antiseptic tablets or solutions. 

An apparatus for the subcutaneous injection of sterile salt 
solution should also be carried. This may consist of a fair- 



ON THE PART OF THE PATIENT 125 

sized exploring-needle, attached to a piece of soft-rubber 
tubing one yard in length, and a four-ounce glass or alu- 
minum funnel. 

Many physicians carry also a freshly laundried linen coat 
and duck apron, as well as a pair of rubber gloves. These 
latter may be sterilized and wrapped up in a package, not to 
be opened till required. 

On the Part of the Patient. 

The labor-room: Where practicable, a large, high, well- 
ventilated room should be selected for the lying-in chamber. 
It should not be exposed to contamination from defective 
plumbing. 

The room selected should be thoroughly cleaned a few days 
before the expected labor if possible, and all unnecessary 
hangings and furniture removed, especially those likely to 
collect dust. It is well to have two or three small tahles 
available for holding basins, instruments, etc. 

All linen and other things provided for the labor should be 
kept under cover in this room, so as to be immediately avail- 
able as required. 

One dozen towels and a half-dozen freshly laundried sheets 
should be ready. 

Two rubber sheets, or sheets of some impervious material, to 
reach across the bed, about four feet wide, should be provided. 

The patient should also make or obtain a labor-pad, about 
three feet square and about three inches thick, made of 
cheese-cloth and filled with surgical cotton or other ab- 
sorbent material. 

Also two dozen vulvar pads made of the same material 
should be provided. These should be two inches thick, four 
inches wide, and ten inches long, and have tail-pieces attached 
to either end to fasten them to the binder. Two or three 
linen or cotton binders should be ready ; each should be a 
yard and a half long and half a yard wide. 

The labor-pad, vulvar dressings, and binders, as well as 
half a dozen towels, should be wrapped in four separate par- 
cels, steamed for half an hour, and then put away and not 
opened till required for use. 



126 THE MANAGEMENT OF NORMAL LABOR. 

The following should also be provided : a bed-pan, a bottle 
of antiseptic tablets for solution, a fountain-syringe, four 
ounces of tincture of green soap, a half-pound package of 
absorbent cotton, and a one-ounce bottle of vaseline, as well 
as a skein of bobbin. 



On the Part of the Nurse. 

The nurse^s first duty is to prepare the patient for labor, 
as has already been described. 

The labor-bed should then be made ready. This should 
by preference be a single bed, with a stiff spring and a fairly 
hard hair-mattress. Over this a rubber sheet should be 
spread and then covered by an ordinary sheet, which should 
be securely pinned at each corner under the mattress. In 
the middle third of the bed another rubber sheet is then laid, 
covered over by a folded draw-sheet, both being securely 
pinned under the mattress at each side of the bed. On this 
the labor-pad is placed when it is required. The bed should 
be accessible from both sides. 

The nurse should see that everything likely to be needed in 
the course of labor has been provided and is at hand for 
immediate use. 

The nurse should see that plenty of hot water is at hand, 
and make ready two jugs of sterile water, covering the tops 
and placing them where the water will rapidly cool. 

A pair of scissors and the necessary ligatures for the cord 
are to be sterilized and placed within reach. 

A small bowl containing a solution of boric acid, and a few 
small cotton sAvabs, should be ready for washing out the child's 
eyes and mouth. 

Wrappings to receive the child should also be prepared, and 
in winter kept warm till wanted for use. 

Use of Anaesthetics in Labor. 

Obstetric anaesthesia differs from surgical anaesthesia in that 
in the former the object is to blunt and not wholly to abolish 
the sensibilities. 



USE OF AN^JSTHETICS IN LABOR. 127 

The prolonged and too free use of ansesthetios during labor 
is capable of harm ; but at the same time it is the duty of the 
physician to relieve the patient of needless suffering and to 
spare her unnecessary exhaustion. 

The rule should be to use an anaesthetic when the pains are 
not well borne without it. The degree of pain which some 
women can endure is wonderful^ while in other cases the 
limit of endurance is soon reached. 

Anaesthetics are usually indicated toward the end of the 
second stage of labor. At the acme of expulsion surgical 
anaesthesia should be induced, as a rule. 

Chloroform or ether may be employed. Chloroform is 
generally preferred, as the necessary quantity is less bulky, 
and it is pleasanter to take. When partial anaesthesia is all 
that is desired chloroform is the more satisfactory ; but in 
cases requiring surgical anaesthesia for any length of time ether 
is undoubtedly the safer and the better. 

Chloroform is said to weaken, and ether rather to stimu- 
late, uterine contractions. Ether should not be employed 
when bronchitis is present, or when the patient is the sub- 
ject of atheroma. 

In eclampsia and tetanic contraction of the uterus chloro- 
form is to be preferred. 

Administration : In cases requiring only partial anmsthesia, 
the administration can be entrusted to the nurse, acting under 
the physician\s direction. A mask or folded towel is held 
over the patient's face, and at the approach of each pain the 
nurse is instructed to sprinkle a few drops upon it. It is 
well in all cases to smear the patient's face with a light coat- 
ing of vaseline, as the anaesthetic may occasionally fall on 
skin and cause considerable irritation subsequently should 
this precaution be overlooked. 

Care should also be taken to remove any false teeth before 
commencing the administration of the anaesthetic. 

When .surgical aricesthe.sia is required for any length of 
time its administration should never be left to the nurse, but 
a physician should be called for this purpose. 



128 THE MANAGEMENT OE NORMAL LABOR. 



MANAGEMENT OF THE FIRST STAGE OF LABOR. 

Preliminary Conduct of the Physician. 

The physician is usually the one person to whom the woman 
in labor looks for help and encouragement in her hour of trial. 

His duty is to win the absolute conficlence of the patient, 
and to inspire her with hopefulness and courage throughout 
the labor. 

His bearing should be quiet and confident, and his manner, 
while firm, should be sympathetic and gentle. 

The effectiveness of a woman's labor depends very consider- 
ably on the preservation of her self-control and the absence of 
strongly inliibiting emotions. The physician cannot afford to 
lose the intelligent assistance of his patient. Nor is he justi- 
fied in adding fear or despair to the suiferings. Thus, what- 
ever he may tell her relatives, he should, after his examination, 
give his patient the impression that all is satisfactory. 

The physician is sent for at this time because the patient 
believes herself to be in labor. In this she may be mistaken. 

On entering the lying-in -room the physician should not pro- 
ceed at once to examine the patient ; but should try to set his 
patient at ease and permit her to become accustomed to liis 
presence. 

In a quiet, conversational manner, information as to the 
time of onset, the frequency, and the duration of the pains 
should be obtained. 

The condition of the patient's general health since the last 
visit of the physician should be learned, etc. 

^yhile thus engaged the physician may watch for himself any 
symptoms of labor which may be manifest, and at the same 
time he should observe his patient carefully for any obvious 
sign of disease as shown in her face or bearing, and seek to 
estimate for himself the character and type of woman with 
whom he has to deal. 

Should it be evident that labor has commenced the nurse 
may then be instructed to prepare the patient, if this has not 
been done already. 

In any case the patient should have the bladder and bowel 
evacuated before any physical examination is made. 



I 



MAyAGEJIEXT OF THE FIRST STAGE OF LABOR. 129 



Obstetric Examination. 

External Examination. 

Preparation : The patient should be placed in the dorsal 
position close to the edge of the bed with her limbs extended 
and her head on a low pillow. The clothing should be 
arranged so as to expose the abdomen from the ensiform car- 
tilage to the pubes. The physician, having washed his hands 
in hot water, may then take a position alongside the patient, 
either sitting or standing as may be more convenient. 

Inspection : The prominence and contour of the abdomen 
should first be observed. The condition of the umbilicus, 
whether depressed or prominent, the presence or absence of 
striae, pigmentation, or scars, and the condition of the flanks 
should all be noted. Evidence of uterine contraction and of 
foetal movements should be looked for. 

Percussion : The abdomen should then be percussed. In 
normal cases the dulness should be limited to central regions 
of the abdomen extending from a short distance above the 
navel to the pubes, wdiile the flanks and epigastric regions 
should give a clear note. 

Palpation, 

Before proceeding to the actual palpation the character and 
temperature of the skin should receive attention. Then the 
degree of panniculus adiposus, and the presence or absence of 
oedema in the hypogastric region, should be noted. The shape 
of the uterus and the height of the fundus should then be 
made out. 

The upper borders of the pelvis should then be examined by 
placing the tips of the fingers of each hand on either iliac 
crest, with the thumb-points resting on the anterior superior 
iliac spines. The relationship of the spines as regards the 
crests should be observed, and a rough estimate of the width 
of this part of the pelvis made. 

The upper border of the pubes should then be located, for 
beginners are very apt to mistake the pubes for the head when 
endeavoring to explore the pelvic excavation from above. 

9— Obst. 



130 THE MANAGEMENT OF NORMAL LABOR. 

The next point is to explore the excavation of the pelvis in 
order to ascertain whether it is full or enipty^ and^ if full, the 
characteristics of that part of the foetus occupying it. In 
order to do this the hands should be placed over the lateral 
aspects of the lower abdomen w^th their palmar surfaces 
almost facing each other, the finger-tips being directed toward 
the patient's feet and resting about an inch and a half above 
Poupart's ligaments. 

The patient is then directed to breathe deeply, and with each 
expiration the finger-tips are pressed downward and backward 
into the pelvis, care being taken to avoid the pubes. In sen- 
sitive patients the pressure exerted may cause pain ; in such 
cases this manoeuvre can be carried out by a series of ballotte- 
ment-like movements, and the information desired thus ob- 
tained with the minimum of discomfort to the patient. 

If the excavation be occupied, the finger-tips are quickly 
arrested in their descent. The only part of the foetus which 
sinks into the pelvis before or very early in labor is the 
head. This may be recognized by its hardness and by its 
globular outline, which can be readily defined. The breech, 
on the other hand, is soft and bulky, and its outline very 
difficult to define. 

Should the head of the ftetus occupy the pelvis in the nor- 
mal condition of flexion (Fig. 62), it will be noted that one 
hand is arrested above the brim, while the other sinks to a 
lower level before meeting wdth resistance. 

The part of the head which is thus most accessible is the 
brow. This condition is most marked in occipitoposterior 
positions of the head. Hence if this fact be noted the posi- 
tion of the foetus is pretty well indicated. 

If the head be located at the brim and the excavation 
of the pelvis not be accessible, it should be noted whether it 
is engaged — that is, fast in the brim — or Avhether it is 
movable. If the head be found to be freely movable, an 
attempt should be made to engage it by pressing it down- 
Avard and backward in the axis of the pelvic inlet, and thus 
to estimate the relative proportions of these ])arts. 

The upper pole of the uterus is pal[)ated by grasping the 
fundus firmly between both hands, having the finger-tips di- 
rected toward the head of the mother. By thus steadying the 



• 



MANAGEMENT OF THE FIRST STAGE OF LABOR. 131 

fundus between the hands, by flexing the fingers the upper 
foetal pole can be palpated for the distinguishing marks of the 
head or the breech. AVhen the head is at the fundus it can 
be readily felt and is very susceptible to ballottement. The 

Fig. 62. 




Palpation with head in pelvic cavity : fingers toward the occiput enter deeper than 
those toward forehead. 



breech is not so movable, is much more bulky, and is more 
difficult than the head to define. 

The foetal back and limbs must then be located. 

The back oifers a broad resisting surface, which is somewhat 
convex from end to end. In certain positions it is not possible 
to feel the back, but in this case the lateral plane of the foetus 
can be felt ; it is narrower than the back, not convex, and the 



132 THE MANAGEMENT OF NORMAL LABOR. 

shoulder can generally be located without difficulty. By 
making firm pressure downward on the fundus with one hand, 
the back, if directed to the front, can be more readily palpated 
with the other. This pressure in the long axis of the foetus 
increases the convexity of the dorsal plane and renders it more 
accessible. 

The limbs are felt as small nodules, knees, heels, elbows, 
etc., which slip about freely under the touch. 

If the small parts are numerous and found near the middle 
line of the abdomen, a posterior position of the foetus is indi- 
cated. Finding of the small parts in one section of the abdo- 
men confirms the location of the dorsum in the opposite region ; 
thus small parts to the right indicate a left, and small parts to 
the left indicate a right position of the foetus. 

Auscultation, 

Auscultation is best practised with the binaural stethoscope. 
It is a mistake to press the bell of the instrument firmly on 
the abdominal wall ; it should be allowed to rest lightly upon 
the skin, being steadied by the slightest touch of one finger 
on the cross-bar. 

The first object is to locate the point at which the foetal 
heart is heard with maximum intensity. 

The foetal heart-sounds are transmitted most loudly through 
the back, generally about tlie lower angle of the left foetal 
scapula. 

In (interior vertex 'presentations the heart-sounds are heard 
best at a point midway between the umbilicus and the anterior 
superior spine of the side to which the foetal back is directed ; 
while in posterior vertex presentations their point of maximum 
intensity is in the corresponding flank. 

Fig. 63 illustrates the points of maximum intensity of the 
foetal heart-sounds in the various positions and presentations. 

The sounds produced by the foetal heart have been com- 
pared to the muffled ticking of a watch under a pillow, the 
rate being about 120-160 per minute. 

It should be remembered that in dorsoposterior positions, in 
hydramnios, and in certain other conditions the heart-sounds 
mav not be audible. 



MANAGEMENT OF THE FIRST STAGE OF LABOR. 133 

The loud rhytluiiic swishing-sound occurriDg synchronously 
with the maternal heart-beat, occasionally heard low down on 
one or other side of the uterus, is termed the uterine bruit. 
This sound is caused by the rushing of blood through the 

Fig. 63. 




Illustrating the points of maximum intensity of foetal heart-sounds in vertex and 
breech presentations. 



enlarged uterine vessels, and is generally to be heard loudest 
in the neighborhood of the placenta. 

Karely a high-pitched hissing or blowing sound, which is 
synchronous with the pulsations of the foetal heart, may be 
heard. This is termed the funic souffle, and is caused by the 
blood rushing through the vessels of the cord. It is, as a 
rule, only heard when the cord is twined around the body of 
the foetus. 



134 THE MANAGEMENT OF NORMAL LABOR. 

Vaginal Examination. 

The physician having completed the external examination 
of the patient, shonld then ascertain the condition of the 
vulva, the vagina, the cervix, and the bag of waters. 

While making the vaginal examination he should note the 
position of the presenting part, and should make a rough esti- 
mate of the capacity of the pelvis. 

Preparations : The patient is placed on her left side, with 
her hips brought Avell to the edge of the bed and her lower 
limbs flexed. The clothing should be so arranged as not to 
interfere with the access of the examining hand, and a sheet 
is then draped over the patient. While this is being attended 
to, the physician should cleanse and sterilize his hands, ac- 
cording to the directions already given. 

The Examination. 

Everything being in readiness, the physician seats himself 
facing the patient's genitalia. The nurse is then directed to 
lift the sheet covering the patient, so as to expose the but- 
tocks. 

With his left hand the physician then gently cleanses the 
vulva with a pledget of absorbent cotton wet with an anti- 
septic solution. 

Having moistened his right hand in the same solution, he 
then separates the lips of the vulva by means of the thumb 
and middle finger of this hand, holding the examining fore- 
finger well flexed into the palm so that it will not come into 
accidental contact with any part of the patient. 

Having thus exposed the orifice of the vagina, he then ex- 
tends his forefinger, passing it gently in in the direction of 
the hollow of the sacrum. 

Having already noted the condition of the vulva and 
vaginal discharge, he now examines the perineum and the 
posterior vaginal wall. The finger is then passed upward 
following the curve of the sacrum, Avhich should be noted, 
until it reaches the posterior vaginal fornix. 

The posterior lip of the cervix will now be felt, and is to 
be traced down till the margin of the external os is reached. 



MANAGEMENT OF THE FIRST STAGE OF LABOR. 135 

The finger is then swept round the external os, note being 
taken of its condition and of the degree of dilatation present. 

The bag of waters is then felt if present ; if not, the 
finger is inserted within the os until the presenting part of 
the foetus is reached. This is then explored for landmarks 
and its position in the pelvis ascertained. 

On withdrawing the finger the anterior lip of the cervix 
should be followed ; and the anterior vaginal wall as wtII as 
the posterior surface of the pubes should be explored. 

Fig. 64. 




Manual method of measuring the diagonal conjugate. 



The capacity of the pelvis should then be ascertained by 
sweeping the finger about in various directions. If possible, 
an attempt may be made to reach the promontory of the 
sacrum ; if this can readily be touched, there is some degree 
of pelvic contraction present. 

The diagonal conjugate should therefore be measured. 

For this purpose the finger should be withdrawn and the 
whole hand again immersed in an antiseptic solution. The 
first and second fingers are then inserted into the vagina, and 
the tip of the second finger placed in contact with the most 



136 THE MANAGEMENT OF NORMAL LABOR. 

prominent i)oint of the promontory ; tlie naclial edge of the 
hand is then raised until it rests against the subpubic liga- 
ment (Fig. 64). This point of contact is then marked by a 
finger-nail of the other hand. On withdrawing the hands 
the distance between the two points of contact is then meas- 
ured and the true conjugate estimated (see Pelvimetry). 

Succeeding the Examination. 

Having now gathered all his facts the physician is enabled 
to make a diagnosis. It is unwise to venture a diagnosis till 
all the facts are in hand. 

Predictions as to the probable duration of the labor should 
be avoided ; but at the same time the patient should be given 
all the encouragement and assurance possible. 

If the presentation be favorable and the part well engaged 
in the pelvic brim, the patient may be allowed the liberty of 
her room, and indeed should be encouraged to move about. 

The attendance of the physician during the first stage of 
labor is not required, in the absence of any complication. 

The nurse should be instructed to give the patient small 
quantities of liquid nourishment at short intervals. It is 
well to leave a couple of 15-grain doses of chloral to be ad- 
ministered to the patient, with an interval of twenty minutes 
between each, should her suffering become acute. The nurse 
should also be instructed to keep the patient in bed, and to 
summon the physician when the membranes rupture or on 
the occurrence of bearing-down pains. 

After an interval of two to four hours, should the mem- 
branes not have ruptured, a second vaginal examination may 
be made to ascertain what progress has been attained. 

Should it be found that the tenseness of the bag of waters 
remains the same during the pains as in the intervals, or 
should the os be dilated so as easily to admit three fingers, 
then the membranes may be ruptured. 

This is accomplished by a scratching movement of the fore- 
finger, accompanied by pressure. Should this fail, a sterilized 
probe or straightened-out hairpin may be employed for this 
])urpose, the greatest care being exercised not to injure the 
maternal tissues nor the skin of the presenting part of the 
foetus. 



MANAGEMENT OF THE SECOND STAGE OF LABOR. 137 



MANAGEMENT OF THE SECOND STAGE OF LABOR. 

During the second stage of labor the patient should be kept 
in bed. Her ordinary night-clothing should be turned up 
and pinned at the shoulder, so as to prevent its being soiled. 

Position: The patient may assume any posture during this 
stage in which she can secure the greatest amount of comfort, 
provided there is no reason why she should be constantly kept 
in one position. 

She should be encouraged to bring all her expulsive efforts 
into operation, and to this end her feet may be braced against 
some object, and she may be allowed to assist herself by either 
pulling upon the hands of a bystander or on a sheet-sling 
fastened to the foot of the bed. 

In rapid cases these measures should be avoided, and the 
patient instructed not to bear down, but to relax her muscles 
by short, panting breathing or by crying out aloud during the 
acme of the uterine contractions. In this way too rapid dis- 
tention and rupture of the perineum may be avoided. The 
physician should be in constant attendance during this stage. 

There is but little occasion to make a vaginal examination 
when the second stage of labor is established. Should it be 
found that advance does not occur in spite of apparently good 
uterine action, then a vaginal examination should be made to 
establish if possible the cause of delay ; but frequent examina- 
tions should be avoided. 

During the second stage an anaesthetic may be employed k) 
control and limit the expulsive efforts of the patient should 
this be desired, as well as to relieve her suffering. Not infre- 
quently it is necessary to employ it in the first stage for the 
latter object. It should only be administered during the 
pains, according to the directions already given. 

When the anus begins to distend with each pain, the head 
has reached the pelvic floor and rotation is under way. 

Perineal stage : It is now the duty of the physician to 
watch the effect of each contraction of the uterus in advancing 
the head. 

As the perineum begins to distend with each pain, not in- 
frequently a small quantity of faecal matter is expelled from 
the anus. This must be washed away, from before backward, 



138 THE MANAGEMENT OF NORMAL LABOR. 

so as to prevent infection, with pledgets of absorbent cotton 
soaked in an antiseptic solution. 

Laceration of the perineum occurs in about 35 per cent, of 
pri mi parse, and in about half that number of multiparse. 
Prevention of this accident depends on the distensibility of 
the pelvic floor and the smallness of the engaging circumfer- 
ence of the fcetal head. Slow delivery of the foetal head, by 
gradual stretching of the perineum, minimizes the possibility 
of rupture. Half the injuries occurring to the pelvic floor in 
general obstetric practice are preventable by skilful manage- 
ment of the perineal stage of labor. 

The patient should at this time be placed on her left side, 
with her hips close to the edge of the bed. Her legs should 
be flexed and a folded pillow placed between her knees. 

The physician should sit close to the edge of the bed, facing 
its foot. Near at hand on a chair or low table should be a 
basin containing an antiseptic solution, in which he may dip 
his hands from time to time, as well as ligatures for the cord, 
scissors, swabs, etc., which he will require as the case pro- 
ceeds. 

The rate of the descent of the head is moderated by con- 
trolling the expulsive eflbrts of the patient and by direct press- 
ure upon the perineum. Should there be evidence of oedema 
of this region, hot fomentations may be applied, care being 
taken first to anoint the parts with carbolized vaseline, so as 
to prevent burning. 

As the moment of delivery of the head approaches the 
physician should slip his left hand over the patient's abdo- 
men and between her thighs, so as to place his fingers on the 
occiput as it emerges below the pubic arch (Fig. 65). By 
exerting pressure with this hand too early extension of the 
head can be prevented, and any of the soft structures of the 
pubic segment of the pelvic floor, which may be caught in 
front of the occiput, can be pushed back in the intervals 
between the pains and held out of the road, so as to permit 
its early escape under the arch of the i)ubes. 

The fingers of the right hand are held on the lower side of 
the vulva, and the thumb on the upper, while the palm covers 
the perineum. 

As the occiput escapes under the pubic arch pressure is 



MANAGEMENT OF THE SECOND STAGE OF LABOR. 139 

made with the fingers and thumb of the right hand, so as to 
push the head forward, and at the same moment the left hand 
firmly grasps it in order to moderate the rapidity of its escape ; 
then the right hand is free to prevent the perineum slipping 
too rapidly over the face. 

As the head escapes from the vulva it is well to have the nurse 
extend the limbs of the patient somewhat, which movement 
results in a certain degree of relaxation of the perineum. 

Fig. 65. 




Protection of pelvic floor and delay of fcetal head. (Davis.) 



With the hands placed as directed above to control the de- 
livery of the head, this extension of the limbs interferes in no 
way with the physician's work. 

During the moment of delivery the anaesthetic should be 
pushed so as to induce surgical anaesthesia, in order to prevent 
any unexpected movement of the mother and also to spare her 
agonizing pain. 

Having delivered the head, the physician may now quickly 
cleanse his hands in the antise})tic solution before proceeding to 



140 THE MANAGEMENT OF NORMAL LABOR. 

examine tlie neck of the child to see if it be encircled by the 
cord. 

Should this be the case, he may draw down the cord and loosen 
the loop sutliciently either to pass it over the child's head or 
to deliver the slioulders through it ; if this be impossible, it 
must be tied, cut, and the child rapidly delivered. 

No effort for a couple of minutes should be made to deliver 
the shoulders after the head has been born, except when the 
labor has been long and difficult. Should they not advance, 
then the anterior shoulder should be reached if possible by 
passing two fingers over the dorsal surface till the arm is 
reached, when it is delivered by flexing the fingers, so that it 
moves over the chest. 

The physician should then place his left hand over the 
fundus of the uterus, making firm pressure upon it, while at 
the same time with his right he pushes the head and body of 
the child forward toward the pubes as it escapes from the 
vulva. 

Immediate care of the child : The nurse should then take 
charge of the fundus, while the physician attends to clearing 
the mucus from the child's mouth and to wiping its eyes. 
Efforts should then be made to establish re^^piration, should 
the child not cry, by slapping it briskly or by sprinkling it 
with cold water. When once it cries lustily it should be laid 
on its side, while the mother is being turned over into the 
dorsal position. 

The cord may now be tied an inch from the navel. A short 
distance beyond this a second ligature is placed, and the cord 
slipped between the middle and third fingers of the left hand, 
which is placed with its dorsum resting on the child's abdo- 
men. The ligatured part of the cord thus lies in the palm 
of the hand, so that in cutting it there is not the slightest 
danger of the child's being injured by the points of the 
scissors. 

The foetal end of the cord should then be washed and 
examined to see that it has been firmly tied, when it may be 
wrapped in a dry piece of sterile gauze. 

The child is then wrapped up warmly and put in a safe 
place till it can be washed. 



MANAGEMENT OF THE THIRD STAGE OF LABOR. 141 

MANAGEMENT OF THE THIRD STAGE OF LABOR. 

In order to insure firm and continuous uterine contraction, 
either the nurse or the physician should take charge of the 
fundus from the moment the head is delivered till the binder 
has been applied. Should the uterus become relaxed a few 
circular movements of the hand over the fundus will stimu- 
late contraction and prevent hemorrhage. 

A sterilized bed-pan or soup plate may now be placed under 
the buttocks so as to catch any blood that may escape from the 
vagina and also to receive the after-birth. 

Lacerations : While waiting for the placenta to be delivered 
many physicians place the nurse in charge of the fundus while 
they utilize this time to examine the vulva and perineum for 
the presence of lacerations. 

Should the lacerations not be extensive^ they may be im- 
mediately sutured according to the directions given in the 
Treatment of Lacerations. The sutures should not be tied 
until the placenta has been expelled ; but their ends may be 
caught in a pair of artery-forceps meanwhile. The advan- 
tage of passing the sutures at this time is that the patient is 
still partially under the influence of the anaesthetic, and the 
operation causes no pain. 

Should the placenta not have been expelled in half an hour 
after the birth of the child, preparations should be made to 
deliver it by Crede's method of expression. 

The patient's limbs are drawn up till her feet rest on the 
bed as close as possible to the buttocks, her knees being widely 
separated. The sheet covering her is then arranged so as to 
expose only the vulva. The physician should then sterilize 
his hands, for in cases where the placenta is found firmly 
attached to the uterine wall, in whole or in part, it is 
desirable that the hand be ready for immediate entrance into 
the uterus. 

With his left hand placed upon the fundus so that the 
fingers are behind and the thumb in front of it, and the thumb 
and forefinger of the right hand grasping the cord just within 
the vulva, the physician, after kneading the uterus to secure 
good, firm contraction, makes strong, steady pressure down- 
ward in the axis of the pelvic inlet, at the same time squeez- 



142 THE MANAGEMENT OF NORMAL LABOR. 

ing the organ firmly. When the placenta is felt to detach itself, 
gentle traction may be made upon the cord so as to guide it 
out of the vagina. 

Should the first attem])t fail, it is repeated with each succes- 
sive contraction until the after-birth is expelled. 

Should the membranes be caught, they may be grasped by 
the fingers of the right hand and gentle traction made upward 
toward the pubes and parallel with the vulva, in order to 
separate them. 

The nurse is now given charge of the fundus while the 
physician carefully examines the placenta and membranes in a 
good light in order to assure himself that no fragment has 
been left behind. Having satisfied himself on this point, he 
may now take charge of the fundus while the nurse pro- 
ceeds to wash the vulva and remove all soiled linen from the 
bed. 

Retraction of the uterus : Should the fundus not retract 
firmly after delivery of the placenta, a drachm dose of the 
fluid extract of ergot should be administered to the patient. 
In all cases the fundus should be gently kneaded for half an 
hour after the delivery of the placenta. When retraction is 
complete the abdominal binder may be put on, a fresh pad 
applied to the vulva, and the patient made comfortable. 

The physician, before proceeding to wash up and collect his 
instruments, etc., should carefully examine the infant for the 
possible existence of developmental anomalies, and to ascer- 
tain that no injuries have been received in the course of de- 
livery. 

For further directions as to the care of the newborn the 
reader is referred to the compend of this Series on Children's 
Diseases. 

Final measures : Before leaving the patient the physician 
should assure himself as to the condition of the fundus, the 
lochia, and the pulse. The nurse should be given full instruc- 
tions with reference to the care of the mother and the child. 
It is w^ell to leave the nurse one or two half-drachm doses of 
ergot to be administered should the fundus show any tendency 
to relax ; she may also be left a prescription for relieving the 
after-pains should they prevent the patient resting. 



THE PUERPERAL STATE— THE UTERUS. 143 

THE PUERPERAL STATE. 

The puerperal period, or puerperium, begins at the termination 
of labor ; and concludes when involution and regeneration of 
the genital organs are completed. 

This period varies in individual cases, but averages about 
six weeks. 

The physiological phenomena of the puerperium are : the 
involution of the uterus and vagina ; disintegration of the 
decidua and the regeneration of the endometrium ; retrograde 
changes in the uterine ligaments, pelvic peritoneum, cellular 
tissue, lymphatics, bloodvessels, and nerves ; alterations in the 
blood and circulatory system ; changes in body-weight, tem- 
perature, and skin, as well as in the urinary and alimentary 
systems ; and finally the establishment of lactation. 

The two opposed processes of decay and regeneration occur 
simultaneously with great rapidity in the puerperium. These 
processes, which involve whole systems and organs, take place 
in the natural healthy woman without affecting her subjective 
condition. 

The puerperal state, though it is physiological, borders so 
closely on the pathological that conditions of disease may very 
readily arise. 

Hence during this period the woman is so beset with diffi- 
culties and dangers that accidents and complications are 
likely to occur unless she is guarded and cared for with 
knowledge and skill. 

Anatomy of the Parts Immediately After Labor. 

The Uterus. 

Position: This organ lies in an anteverted and anteflexed 
state with its fundus in contact with the anterior abdominal 
wall. Its shape is usually an irregular ovoid. 

The upper uterine segment is thick- walled (IJ inches, 3 to 4 
cm.), and is pale pink in color on section. 

The lower uterine segment is separated from the upper by a 
well-marked line. Its walls being much thinner, are thrown 
into folds by the weight of the upper segment. 



144 THE PUERPERAL STATE. 

The cervix can roughly be made out, its walls being 
rather thicker than the lower segment. The li23S are usually 
everted, resting on the posterior vaginal wall, and are flattened 
by the weight of the uterus. 

The lower segment and cervix are much congested, and 
thus contrast with the bloodless body of the uterus. 

The placental site, which measures roughly 4 by 3 inches, 
has a ragged surface, and is somewhat elevated. It shows the 
openings of the sinuses filled with clots. The area of the at- 
tachment of the membranes is paler in color and smoother than 
the placental site. Shreds of decidua are scattered over the 
surface. 

The cavity of the uterus measures 6 to 6^ inches (15 to 16 
cm.) in length. 

The Vagina. 

It retains its usual shape, but is much distended. Its walls 
are thickened and their surface smooth and oedematous ; ' they 
also present more or less evidence of contusion or abrasion. 

The Vulva. 

The vaginal orifice is stretched and torn to a variable degree. 
All the external parts are frequently somewhat bruised and 
lacerated, and may also present more or less oedema. 

The pelvic floor is greatly relaxed and not infrequently torn, 
the edges of the wound in this case gaping somewhat. 

The Bladder. 

This lies in its usual position, and is once more a pelvic 
organ. 

The Peritoneum and Broad Ligaments. 

The peritoneum over the body of the uterus is smooth ; but 
at the mdes and at Douglas's pouch it is thrown into folds. The 
broad Ugmnents lie folded and to a certain extent compressed 
between the body of the uterus and the pelvic walls. This 
compression of the broad ligaments must retard the circula- 
tion in the vessels contained in them, and so lessen the en- 
gorgement of the uterus. 



INVOLUTION. 145 

The abdominal walls are relaxed and the skin usually 
thrown into folds and wrinkles. 

Physiology of the Puerperal Period 

Involution. 

The uterus : Immediately after the expulsion of the placenta 
the fundus of the uterus may be felt about half-way between 
the umbilicus and the pubes ; but in a short time, from one to 
six hours, it will be found to occupy a position at or slightly 
above the umbilicus. The dilatation of the lower uterine seg- 
ment and cervix necessary to permit the passage of the child 
results in more or less complete loss of tone, so that the weight 
of the upper segment compresses them ; but as tone is re- 
gained they become capable of supporting the superimposed 
weight and the fundus becomes elevated slightly. 

From this time the uterus diminishes rapidly in size, so that 
the fundus gradually sinks, and at the tenth day may be found 
at the level of the pelvic brim. 

Involution of the uterus proceeds most rapidly between the 
third and the twelfth day of the puerperal period. The uterus 
never quite returns to its virginal condition, its cavity in the 
parous woman being about half an inch longer than in the 
virgin. 

Changes in the muscle-cells : The firm contraction and 
retraction of the uterus, after labor, cut off its blood-supply 
to a very considerable extent, and thus being deprived of 
nourishment the muscle-cells rapidly undergo fatty degenera- 
tion. At the same time a portion of the cell-contents is con- 
verted into a peptone, which is absorbed into the blood and 
discharged through the kidneys. 

It is doubtful if any cells are destroyed in toto ; for 
Sanger's observations prove that reduction of the uterus after 
labor is effected by a diminution in size of the individual cells 
and not by their destruction. 

Changes in the uterine vessels and nerves : The bloodvessels, 
lymphatics, and nerves have all participated in the general 
growth during pregnancy. These all take on retrograde 
changes. The bloodvessels, which are closed by thrombi, are 

10— Obst. 



146 THE PUERPERAL STATE. 

compressed, thus bringing their walls in apposition. Partly 
by organization of the clots and partly by excessive growth 
of connective tissue in the walls, the vessels become ob- 
literated. 

Uterine mucosa : The ovum when it is cast off carries with 
it chiefly the upper layer of the decidua, which remains 
attached to the chorion, and leaves behind on the uterine wall 
the lower cellular layer and the glandular portion. 

Diminished blood-supply from uterine retraction soon 
results in loss of vitality in the lower portion of the 
decidua, fatty degeneration and disintegration of the cells 
rapidly ensue, and they are cast off in the lochial discharge. 
This process soon lays bare the glandular layer from which 
the new mucous membrane originates. The epithelial cells of 
the glandular layer as well as the interglandular connective 
tissue rapidly proliferate and form the new mucous membrane. 
This process takes about eight weeks to complete. 

Lochia : The term lochia is applied to the discharge which 
comes from the vagina of the puerperal woman. 

It is composed of blood, degenerated epithelial cells, debris 
of clots, mucus, and quantities of harmless micro-organisms. 
It begins after the placenta has been delivered, and lasts from 
ten to fourteen days. 

Its character changes as the puerperium advances. At first 
it mainly consists of pure blood mixed with cervical mucus 
and small clots — the lochia rubra. In two or three days it 
becomes paler and consists of serum and mucus — the lochia 
serosa. About the sixth day it becomes thicker and is choco- 
late colored ; but as the blood disappears and leucocytes become 
more abundant, it is white, having the appearance of thin pus, 
which it practically is — the lochia alba. 

Frequently when the patient first assumes the erect posture 
the lochia again becomes tinged more or less with blood. 

Its quantity was formerly greatly overestimated by Gassner, 
who gave it as about fifty ounces. Recently Giles, from care- 
ful measurement in a large number of cases, estimated the 
total quantity as being only ten and a half ounces. 

Its odor is peculiar. The lochia rubra has the odor of fresh 
blood ; but later the mucus from the vulvar glands gives it a 
peculiar and somewhat penetrating odor. Practically the odor 



CHANGES IN THE UEINARY SYSTEM. 147 

may be defined as an acid odorwlien the discharge is normal. 
Ammoniacal or alkaline odor always suggests that putrefactive 
germs have gained access to the vagina. 

Vulva and vagina : In primiparse the hymen and fourchette 
are invariably torn ; the remains of the former persist around 
the vaginal orifice in the form of small irregularly shaped 
elevations which are termed carunctdoe myrtiformes. 

More extensive tears of the vulva and perineum, if not 
sutured, heal by granulation and cicatrization, occasionally 
leaving extensive scars. 

The vagina rapidly becomes smaller and narrower ; its walls 
from being smooth, gradually become rugated though the 
rugse are never so marked as in the nullipara. As the hyper- 
semia of the parts passes off, the vulva and vagina assume 
more their previous color and proportions. 

Involution also takes place in the uterine ligaments, ovaries 
and tubes, abdominal walls, and pelvic joints, all gradually 
returning more or less to their condition as before the occur- 
rence of pregnancy. 

Changes in the Circulatory System. 

Pulse : The pulse-rate shortly after labor falls to about 60, 
or even lower. The cause of this lies in the reduction of the 
general blood-pressure due to changes in the constitution of 
the blood and also to the decreased intra-abdominal pressure. 

The blood, probably as the result of hemorrhage during and 
after the third stage of labor, becomes deficient in red blood- 
corpuscles and haemoglobin. 

The heart, which has become slightly hypertrophied during 
pregnancy, quickly resumes its former condition. 

Changes in the Urinary System. 

The urine is not markedly increased in quantity. Peptone 
and acetone are said to be normally present in the urine of 
puerperal women. The occurrence of sugar is not unusual, 
especially when there is distention of the breasts. Albumin 
may be present for a few days, but its persistence is always of 
grave import. 



148 THE PUERPERAL STATE. 

The bladder not infrequently becomes overdistended in 
puerperal women and micturition impossible. The causes 
of this condition are twofold : First, the bladder is now 
subjected to less pressure than it was, because the greatly 
distended uterus has been emptied, in consequence of which 
the intra-abdominal pressure is greatly decreased and the 
abdominal walls flaccid ; hence the bladder has more room 
to distend and less resistance is offered to it. Second, small 
fissures about the vulva smart severely when the urine trickles 
over them, hence the woman is led almost unconsciously to 
retain her urine as long as possible. 

The Skin. 

During the puerperium the sweat-glands become unusually 
active. The skin is more moist and not infrequently during 
sleep profuse perspiration takes place. This is probably one 
of the factors by which the hydrsemia of pregnancy is cor- 
rected. 

The Digestive Apparatus. 

The power of digestion of solid food is for a time enfeebled. 

Thirst is usually present, and is easily accounted for by the 
great drain of water from the body by perspiration, the lochia, 
the milk, and the urinary secretion. 

The bowels are apt to be sluggish, constipation being usu- 
ally present, probably caused by the decrease in intra-abdom- 
inal pressure, the lax condition of the abdominal wall, and 
the great drain of water from the system referred to above. 

Loss in weight takes place rapidly, as elimination exceeds 
ingestion during the puerperium. This loss is very marked 
in most cases, and has been estimated at from one-twelfth to 
one-eighth the body-weight in the first seven days. This 
diminution should cease by the tenth day. 

Lactation. 

By lactation is meant the suckling of the infant. It usu- 
ally commences on the third day and lasts for about a year ; 



LACTATION. 149 

though after the seventh or eighth month there is a falling 
off in the quality of milk secreted. 

The mammary glands are two large racemose glandular 
organs situated on the upper portion of the chest, anterior 
to the muscular structures of the thoracic walls. They 
occupy the space bounded above by the third rib, and below 
by the sixth rib ; on the inner side by the edge of the 
sternum, and on the outer by the anterior axillary line. 

They are epiblastic in origin and belong essentially to the 
skin ; as do the sweat and sebaceous glands. 

They are globular, and vary in size in different women. 

At the summit of each breast is a small conical elevation 
known as the nipple, which is surrounded by an area of pig- 
mented skin, termed the areola, in which there is a number of 
large sebaceous glands — the glands of Montgomery. 

Internally each mammary gland is composed of from 
fifteen to twenty-four lobes, united by a certain amount of 
connective tissue and fat. Each lobe is divided into lobules, 
and these are further subdivided into a large number of 
acini or vesicles, in which the milk is secreted. 

The vesicles empty their contents into small ducts ; these 
excretory ducts from contiguous lobules unite to form a 
single large lactiferous canal. 

Of these latter there are fifteen or more in each breast, 
each conveying the milk from a separate lobe to the nipple. 
The epithelium lining these canals is continuous with that of 
the integument. 

Colostrum : Until the establishment of lactation the breasts 
contain only '^ colostrum," which is a yellowish fluid resemb- 
ling milk, but differing from it chemically, in that it contains 
more sugar, fat, and salts. It has a laxative effect on the 
child, due to the excess of fats and salts it contains. Micro- 
scopically it can be recognized by the large, so-called colos- 
trum-cells, which are simply large epithelial cells studded 
with fat-globules. 

Milk is the secretion of the mammary glands. It is a 
yellowish-white fluid of an alkaline reaction having a specific 
gravity of 1024 to 1034. 

Good human milk has approximately the following chemi- 
cal composition : 



150 THE PUERPERAL STATE. 





Per cent 


Fat, 


4.00 


Sugar, 


7.00 


Proteid (casein), 


1.50 


Salts, 


0.20 


Water, 


87.30 



The fats, sugar, and proteids are produced from the cells 
lining the acini of the glands; the plasma and salts are de- 
rived from the blood. 

The CLuality of the milk is altered by varied conditions of 
the mother ; mental and physical disturbances may so change 
the milk as to render it unwholesome. 

The quantity of milk secreted varies in different women and 
at different times. At first about 200 c.c. is secreted daily, 
but after the tenth day the amount increases to from one-half 
to two litres. 

The secretion of milk usually begins about forty-eight 
hours after labor. The breasts distend, become engorged with 
blood, and are painful or tender when touched. 

AVhen the breast is full it is hard and nodular to the feel, 
and milk may be expressed from the nipple on the slightest 
pressure. 

The establishment of lactation may be painful, and may 
give rise to considerable emotional disturbance on the part 
of the patient, causing a slight elevation of temperature; this 
is, however, rare except in primiparse. There is no such 
thing as the so-called ^'milk fever''; if fever occur at this 
time, it is a traumatic fever, and the result of infection only. 

The Management of the Puerperium. 

The lying-in-room should be in the quietest part of the house 
if possible. It should be well ventilated, and the light should 
be so arranged as to cause no inconvenience to the patient. 
It should be kept thoroughly clean and well dusted. The 
tem])erature of the room should be maintained at between 65° 
and 70° F. Soiled linen should l)e taken from the room as 
soon as possible after being removed from the patient. The 
patient's linen and draw-sheet should be changed daily. 



I 



CARE OF BREASTS, NURSING, ETC. 151 

Friends and relatives should not be permitted to use the 
room as a general meeting-place. 

The care of tlie genitalia : The vulvar dressings should he 
changed at least every three hours during the first twenty- 
four; after this as often as soiled, or three or four times 
daily. 

AVhen the pad is removed the external genitals should be 
cleansed of lochia by means of swabs dipped in a saturated 
solution of boric acid and squeezed dry, before a fresh dress- 
ing is applied. 

After the bed-pan has been used the lips of the vulva should 
be gently separated and a stream of warm boric-acid solution 
poured over them from a douch bag or small jug. The parts 
should then be carefully dried with a sterile towel or bits of 
gauze and a fresh dressing applied. 

All manipulations should be carried out with the strictest 
aseptic precautions. 

Care of Breasts, Nursing, Etc. 

The child should be put to the breast for a few" moments 
every six hours until the secretion of milk is established. 
This may be supplemented by an occasional ounce of sweet- 
ened water should the infant prove restless. 

When lactation is established the child should be suckled 
every two hours from 6 a. m. to 10 p. m. Usually it is 
necessary to give one nursing during the night for the first six 
weeks. The importance of regularity in nursing should be 
impressed upon the mother, for without regularity it is scarcely 
possible for mother or child to do well. Overfrequent and 
irregular nursing deranges the infant's digestion and impairs 
the quality of the milk. 

The nipples should be cleansed with a saturated boric- 
acid solution, both before and after suckling. 

In drying the nipples only absorbent cotton or soft gauze 
should be employed, and care should be taken not to rub 
them. 

Should they become tender any antiseptic emollient may be 
applied. The following makes a very satisfactory ointment 
for this purpose : 



152 THE PUERPERAL STATE. 

I^. Acid, boric, 3J ; 

Bismiitli. snbnit., 

Ol. ricini, da 5ss. — M. 

Ft. ling. 
Sig. To be applied after nursing, and covered with a small 
square of white waxed paper. 

It may be necessary to use a well-fitting glass nipple-shield 
for a short time, should the act of suckling give rise to irrita- 
tion of the nipples. 

Not infrequently, usually in women with large, pendulous 
breasts, considerable discomfort, even amounting to pain, is 
suffered when the glands become distended with milk. In 
these cases a snugly fitting breast-binder will afford great ease 
and comfort. Either the Murphy or the Y binder may be 
employed. 

Contraindications to suckling : While suckling benefits the 
mother by promoting involution through reflex nervous ac- 
tion, and while there is certainly no food so suitable for the 
infant as mother's milk, there are still certain conditions 
which may render it unwise for the patient to nurse her child. 

A feeble state of health, tuberculosis, and persistent albu- 
minuria all contraindicate suckling. The same applies to 
cases in which syphilis has been contracted late in pregnancy, 
for it is possible the child may have escaped infection. 

Inversion of the nipples, or severe and painful fissures, 
mastitis, or defective secretion, all act as contraindications of 
suckling. 

Nourishment: As the process of digestion is usually im- 
paired during the first days of the puerperium, the diet at this 
period should consist chiefly of fluids. Milk, clear soup, 
gruel, cocoa, week tea, toast, stale bread, and soft-boiled eggs 
may be permitted. After the third day a gradual return to 
the usual diet may be made. Malt liquors and wines may be 
permitted in small quantities if patients are accustomed to 
their use. 

Rest : Everything about the patient should be so disposed 
that she may obtain absolute mental and physical rest. It is 
not necessary, provided uterine retraction be firm, for the 
patient to remain constantly on her back ; she may gently turn 



CARE OF BREASTS, NURSING, ETC. 153 

over to one or other side should she so desire. After the 
first day she may be allowed to rise almost to the sitting 
posture for a short time, should there be occasion, the use of 
the catheter thus being rendered unnecessary. All move- 
ments should be slow and deliberate, sudden changes of posi- 
tion being always avoided. 

After-pains: In primipara? after-pains due to uterine con- 
tractions are seldom severe enough to demand relief. In 
multiparse, on the other hand, they may be so troublesome as 
to preclude all possibility of rest or sleep. Morphine gives 
relief, but should be used with care. Doses of J-J gr. may 
be repeated as often as required. When it is undesirable to 
use this drug, antifebrin or phenacetin in gr. v doses, com- 
bined with caifeine cit., gr. ij, m^y be given. 

Should the uterus remain lax and soft, involution may be 
promoted by friction of the fundus ten minutes two or three 
times daily, and a pill containing : ergot., gr. ij ; quin. sulph., 
gr. ij ; strych. sulph., gr. -^ ; may be given twice or thrice in 
the twenty-four hours. After the fifth day a hot vaginal 
douche, night and morning, may prove of value in this condi- 
tion. 

Visits of the physician : The first visit after labor should be 
made within twelve hours, and afterward one or two visits 
daily, as the case may require. While the patient may be 
allowed " out of bed ^' when once the uterus has become a 
pelvic organ, still she should continue under the physician's 
observation until fully convalescent. 

The nurse in charge of the case should record, morning and 
evening, the temperature, pulse, and respiration, as well as 
evacuations of the bowels and bladder, and the condition of 
the lochia. 

At each visit the physician should note the record of the 
pulse, temperature, respiration, etc. He should also exam- 
ine the condition of the uterus, the bladder (bearing in 
mind the danger of distention of the latter), the breasts and 
nipples, the skin, the digestive apparatus, and the lochia. 

The bowel having been pretty well cleared at the onset of 
labor, it is seldom that a purgative is required till the third 
day. It is usual to give a dose of castor oil or other laxative 
so as to operate on the morning of the third day ; after this a 



154 PATHOLOGY OF PREGNANCY. 

daily movement should be obtained, and a mild laxative 
should be regularly administered if required. 

The infant's temperature should be taken twice daily until 
two days after the separation of the cord, which usually takes 
place in from five to ten days. 

It should be a routine practice to make a bimanual examina- 
tion of the pelvic organs in the third or fourth week of the 
puerperium, with the object of determining the presence or 
absence of injuries of the vagina and cervix, the degree of 
uterine involution, and the existence of displacement of the 
uterus or other abnormal conditions. 



PATHOLOGY OF PREGNANCY. 

THE DECIDUA. 

The decidual mucous membrane of the pregnant uterus may 
be the seat of disease, owing to the enormous hypertrophy of 
the mucous membrane incident to pregnancy. These diseased 
conditions often manifest themselves in exaggerated forms as 
compared with the non-pregnant state. In consequence of 
the relation of the decidua to the ovum, diseased conditions 
of this membrane may have more serious consequences than 
in the non-gravid state. Most decidual diseases have their 
origin in either acute or chronic endometritis. 

Acute Decidual Endometritis. 

Etiology : This is a very rare condition. It may result 
from trauma, in consequence of attempts to procure abortion ; 
or from certain infectious diseases. AYhen due to trauma the 
inflammation is frequently of a septic nature, and is charac- 
terized by the presence of an offensive purulent discharge. 
Deciduitis accompanying the develoj)ment of infectious dis- 
eases during pregnancy usually results in abortion. This 
result is probably due to the hypertrophied mucosa, because 
of its vascularity, becoming the seat of an intense inflamma- 
tion and participating in the eruption which usually affects 
the mucosa of the body in exanthemata. 

The treatment in these cases consists in controlling hemor- 



CHRONIC DECIDUAL ENDOMETRITIS. 155 

rhage, favoring abortion, and attending to complications as 
they arise. 

Chronic Decidual Endometritis. 

Occurrence : Chronic inflammation of the decidua is very 
common ; and is the cause of a vast majority of early abor- 
tions. Usually the inflammation of the endometrium ante- 
dates the pregnancy. 

Two forms are commonly observed, a chronic diffuse endo- 
metritis, or polypoid degeneration ; and a catarrhal endometritis, 
or hydrorrhoea gravidarum. 

In diffuse endometritis there is more or less hyperplasia of 
the connective tissue, resulting in great thickening of the 
decidua. 

Should the disease advance with great rapidity an abortion 
will usually result, either from hemorrhages into the mucous 
membrane, thus separating it from the uterine wall ; or from 
the death of the embryo owing to crowding of the ovum by 
the rapidly thickening decidua. In the latter case the em- 
bryo may be absorbed, and the decidua afterward cast off as 
an empty sac with greatly thickened walls, forming what is 
known as 3. fleshy mole. 

If the inflammation of the decidua be of a more chronic 
character, the pregnancy may proceed to term. In this case 
the parturition is likely to be prolonged by reason of the un- 
due adhesion of the membranes ; or great difficulty may be 
encountered in the third stage from adhesion of the placenta 
to the uterine wall. 

In the catarrhal form of chronic deciduitis there is present 
not only a proliferation of the cellular elements of the decidua, 
but also increased secretion — hydrorrhoea gravidarum. In 
this form there takes place, every few days, a discharge from 
the uterus of a greater or less quantity of a clear viscid 
liquid having a yellowish tinge and containing albumin. 
Hydrorrhoea occurs more frequently in multiparse than in 
primipanie. The discharges may begin early in the pregnancy, 
but usually occur toward the end. 

The treatment consists of keeping the patient as quiet as 
possible. An anodyne may be administered should uterine 
contractions accompany the escape of fluid. Vaginal douches 



156 

are likely to do more harm than good, and should not be em- 
ployed. 

Atrophy of the decidua: Very often the decidiia may fail 
to develop as it should during pregnancy, tending to prolapse 
of the ovum, and ultimately to abortion. 



THE FCETAL APPENDAGES. 

The Amnion. 

The amnion, like serous membranes, is liable to be the site : 
of changes of secretion ; and of the formation of plastic exu- 
dates and bands of adhesion. 

Oligohydramnios, or Deficiency of the Amniotic Fluid. 

The cause of this condition is imknown ; it is usually 
associated with deformities of the foetus. 

The quantity of fluid may be so much below normal as 
seriously to interfere with the growth of the foetus and thus 
to cause its premature expulsion. 

The condition cannot be recognized before labor begins. 
Labor is apt to be tedious, owing to the absence of the fluid 
wedge of the " bag of waters.'^ 

Hydramnios, or Dropsy of the Amnion. 

Definition : The conventional limit of the quantity of liquor 
amnii is given as from two to four pints. Should this be ex- 
ceeded tlie condition of hydramnios exists. 

Occurrence : In frequency it is a comparatively rare con- 
dition, if the term be restricted to cases in which the quantity 
of fluid is sufficiently in excess to cause symptoms. It has 
been stated to occur in about 1 in every 150 to 200 cases; it 
occurs more frequently in multigravidse and in twin preg- 
nancies. 

Etiology : Until tlie origin of the liquor amnii has been 
satisfactorily explained tlie etiology of this condition must 
remain a purely hypothetical problem. It may be due to 



HYDRA My lOS, OR DROPSY OF THE AMNION. 157 

oversecretiou or to deficient absorption of the liquor amnii. 
Some authorities hold that this fluid is derived from the 
blood-current of the mother through the chorion and the 
amnion by transudation. Others consider it is produced 
solely by the foetus, either as an excretion from the kidney 
and skin or by a process peculiar to the amnion. 

Symptoms: As a rule, hydramnios does not develop before 
the fifth or sixth month of gestation, though it may occur as 
early as the tenth week. Usually the first sign to attract the 
patient's attention is the undue enlargement of the abdomen, 
which is usually out of proportion to the period of pregnancy. 
Thus at the sixtli month the uterus may reach the diaphragm. 
This great distention gives rise to oedema of the lower limbs, 
palpitation of the heart, and dyspnoea. Locomotion becomes 
difficult, the functions of the liver or kidney may be inter- 
fered with, and icterus or albuminuria develop ; sleep may 
also be interfered with, and the patient becomes worn and 
haggard. 

On palpation the uterus is tense, and tlie foetus, if felt, Avill 
be found preternaturally mobile ; while on auscultation the 
heart-sounds may be feeble or inaudible. 

Diagnosis : The condition is to be differentiated from twin 
pregnancy, ascites, and ovarian cysts, as follows : 

In twin pregnancy the enlargement of the abdomen begins 
earlier and not abruptly at about the sixth month ; the preter- 
natural mobility of the foetus is not present. Two foetal heart- 
sounds in different parts of the abdomen may be heard. It 
may be possible to palpate two foetal heads and bodies. 

In ascites the symptoms of pregnancy are absent, but it is 
quite possible that both conditions may be present in the same 
case. On percussion a dull note is obtained in the flanks, 
while the central portions of the abdomen are tympanitic. In 
hydramnios the dulness is in the central region of the abdomen 
while the flanks are tympanitic. In ascites change in the 
patient's position alters the location of the tympanitic areas. 
In ascites organic disease of the heart, liver, or kidneys will 
be found to exist. 

Ovarian cyst is to be distinguished by the history and phys- 
ical signs ; the growth is more gradual and longer in develop- 
ment. Menstruation is generally present. The fluid wave is 



158 PATHOLOGY OF PREGNANCY. 

more pronounced. No foetal parts can be palpated. A 
bimanual examination will permit the uterus to be differen- 
tiated from the tumor. The enlargement of the abdomen is 
not, as a rule, as symmetrical as in hydramnios. 

Prognosis : For the mother this is usually favorable, but 
probably one-fourth of the children are born dead or non- 
viable. The risk to the mother is increased by the tendency 
to malposition of the chihi, by overdistention of the uterus 
leading to changes in its structure which render hemorrhages 
during and subsequent to labor more frequent, and by the 
increased liability to collapse following the sudden escape of 
fluid. 

Treatment : The abdomen may be supported by a properly 
fitting abdominal binder; the patient should be kept at rest 
as much as possible. When the distention becomes extensive 
and serious symptoms develop then the membranes should be 
ruptured. When this is done the liquor amnii should be 
allowed to escape slowly and precautions should be taken to 
avoid syncope. Strychnine (gr. y^-) and fl. ext. of ergot (3j) 
should be administered after the placenta has been delivered, to 
insure good uterine contraction and to avoid the risks of post- 
partum hemorrhage. 

Other Affections of the Amnion. 

Amniotic bands : Early in embryonal life should there not 
be sufficient liquor amnii present to separate the amnion 
from the early formed skin of the embryo, adhesions may 
form between the skin and the amnion. As the amniotic 
cavity becomes distended the adhesive material becomes 
stretched, finally forming bands of greater or less length 
and thickness. No satisfactory theory has been advanced to 
explain the pathology of this condition. Braun regards the 
adhesions as resulting from folds of amnion, inflammation of 
the amnion being impossible, as it contains no bloodvessels. 

The bands thus formed result in producing grave deform- 
ities in the fetus, such as eventration, anencephalus, amputa- 
tion of the limbs, etc. The foetal cord may be artificially 
shortened, or even completely severed by such amniotic 
bands. 



HYDATIDIFORM DEGENERATION OF CHORION. 159 

Premature rupture of the amnion : Several cases have been 
reported where later on in pregnancy the amnion has under- 
gone rupture and yet the integrity of the ovum has been pre- 
served by the chorion. The amnion in these cases is usually 
found rolled upon itself and forming a sort of cuif about the 
placental end of the cord. 

Alterations in the character of the liquor amnii : The liquor 
amnii is a clear limpid fluid in the earlier months of gesta- 
tion ; later on it becomes thicker and contains small whitish 
flakes derived from the vernix caseosa. In cases of death of 
the foetus with maceration, the fluid becomes much thickened, 
of a dirty brownish or greenish color, and occasionally emits a 
foetid odor. 

The Chorion. 

Hydatidiform Degeneration of the Chorion, or Vesicular Mole. 

Occurrence : This is the only disease of this membrane 
which is in any degree common. 

It is characterized by hypertrophy of the chorionic villi, 
and by their conversion into cysts varying in size from that 
of a millet seed to a hen's ^gg. These cysts are connected to 
each other and to the base of the chorion by pedicles of 
various lengths and are filled with a fluid much resembling 
the liquor amnii (Fig. 66). 

Pathology : The degeneration of the chorion usually begins 
not later than the tenth week ; as a rule the whole membrane 
is involved and the foetus perishes; in fact it is seldom to be 
found when the mole is expelled. The epithelium lining the 
chorionic villi is the part first affected, it undergoes a marked 
proliferation which distends each villus and thus the grape- 
like bodies are produced. Occasionally when the disease 
comes on late it may be limited to the placenta. In excep- 
tional instances the growth may encroach on the uterine wall 
and even penetrate the peritoneal covering. 

Etiology : Nothing definite is known as to the cause of the 
disease. It occurs most frequently between the ages of twenty- 
five and forty years. 

Vesicular mole — symptoms : Three symptoms are available 
for the diagnosis of this condition : 



160 



PATHOLOGY OF PREGNANCY. 



(a) There usually occurs a more or less profuse serosan- 
f/uineous discharge from the uterus resembling red currant- 
juice. This discharge may be continuous or intermittent. 



Fig. 66. 




X 

Vesicular mole. (Modified from Ribemoi;t-Des>saigncs and Lepage.) 

(h) A .mdden and rapid int'reaHe in the size of the abdomen, 
in which the uterine enlargement does not correspond to the 
sup])o.sed period of gestation. 

(c) The expulsion of cysts from the vagina. This is the only 
pathognomonic symptom and is comparatively rare. The 




ANOMALIES OF THE PLACENTA. 161 

uterus usually presents a doughy feel and foetal movements 
and ballottement are absent. The condition may be confounded 
with placenta praevia and hydramnios. 

Prognosis : This is rarely grave for the mother, but is gen- 
erally fatal for the child. The dangers which threaten the 
mother are hemorrhage and septic infection. 

Vesicular mole — treatment : The uterus should be emptied 
as soon as a diagnosis is established. The patient should be 
anaesthetized, the os dilated, and the growth slowly removed, 
the hand only being used for this purpose. Should it be im- 
possible completely to clear the uterus in this way, then the 
blunt curette may be employed ; but it must be borne in mind 
that the uterine wall may be so thinned out in areas as to be 
very easily penetrated. This should be followed by a hot 
uterine douche and, if uterine retraction fails, the cavity of 
the uterus may be packed with iodoform or plain sterilized 
gauze. 

Anomalies of the Placenta. 

Of position, size, shape, and weight : Normally the position 
of the placenta is near the fundus uteri, but it may occupy 
any position on the uterine walls (see Placenta Prcevia). 

In size it may vary considerably. In conditions of chronic 
inflammation of the endometrium the placenta may be ab- 
normally thick and enlarged in all directions. Atrophy of 
the decidua or interstitial overgrowth followed by retraction 
may cause the placenta to be abnormally small. In this case 
the foetus will be found ill developed. 

The following varieties as to shape may be encountered : 

Placenta membranacea : The villi may persist over the 
entire surface of the chorion and may all develop equally. 

Crescentic, or horseshoe placenta : This is a very rare form. 

Battledore placenta : In this form the cord is inserted at 
the margin of the placenta. Occasionally an accentuation of 
this form is seen, in which the vessels from the cord branch 
out before reaching the placenta — this is termed a velamentous 
insertion of the cord. 

Placentae succenturiatse : Tliere may occasionally be found 
two or more distinct masses of placental tissue produced by 
the growth of isolated patches of chorionic villi. The vessels 

11— Obst. 



162 PATHOLOGY OF PREGNANCY. 

of each patch course along the membranes to unite with those 
going to the cord. In multiple pregnancies each child may 
have its own placenta. 

Diseases of the Placenta. 

Calcareous degeneration of the placenta : Deposits of lime 
salts in the placenta are not uncommon. These deposits only 
occur as fine sand-like particles, or as scales. They usually 
occur at the edges, though they may be found in the substance 
of the cotyledons ; and consist of amorphous phosphates 
and carbonates of lime and magnesia. They cannot be said 
to have any pathological significance. 

White infarctions : Yellowish or grayish masses of degener- 
ated placental tissue are to be found in nearly every placenta. 
AVhen small and few in number they have no pathological 
significance ; but if extensive, foetal death may result. 

Fatty degeneration of the placenta may occur as the result 
of some local obstruction of blood supply to the parts affected. 
Small areas are commonly observed close to the margin of the 
placenta. If extensive degeneration occurs the function of 
the placenta may be interfered with and the foetus perish. 

Placental Apoplexy. 

Definition : This is an effusion of blood either within or be- 
hind the ])lacenta. If it takes place before the third month 
the eflPused blood may force its way between the loose attach- 
ments of the decidua and chorion and thus result in abortion, 
a very common occurrence. 

Joncquemin described three well-marked forms of placental 
apoplexy as follows : 

{a) Tlie effusion takes place directly into one or more 
placental cotyledons forming here and there small soft clots. 

(6) The effusion leads to destruction of portions of placenta 
forming irregular cavities which are surrounded by infiltrated 
and reddened areas. 

(c) The effusion may occupy a number of clearly defined 
irregular cavities of varying sizes, from millet seed to a 
pigeon's Qgg, which are not surrounded by areas of infiltra- 



PLACENTITIS. 163 

tion. In time these apoplectic areas lose their color, become 
denser, and form yellowish-white masses. 

Causes : Placental apoplexy is determined by diseased 
states of either the maternal or the foetal structures entering 
into the formation of the placenta. Most commonly the 
cause is maternal in origin, as nephritis and albuminuria, 
which produce increased arterial tension and venous con- 
gestion. Traumatism, as a blow or kick upon the abdomen, 
may produce it. 

Rarely the cause lies in diseased conditions of the fcetal 
villi leading to rupture ; when the umbilical vessels are dis- 
eased, rupture of one or more of their branches may result 
in exsanguination of the foetus and its death. 

The results of placental apoplexy depend on the stage of 
gestation at which the hemorrhage occurs, the number of 
clots formed, and the extent of placental tissue involved. 
After the third month placental apoplexy but rarely results 
in abortion or premature labor. If the effusion is large and 
the placenta situated low down, the blood may dissect its 
way down to the os and escape, constituting accidental hemor- 
rhage. Large efiPusions may result in destroying so much of 
the placenta that the nourishment of the foetus is impaired 
to such an extent that it is born feeble and puny. 

Placental apoplexy — symptoms : Slight hemorrhage gives 
rise to no symptoms ; large hemorrhages give rise to pain 
and tenesmus. If these symptoms are produced, then death 
of the foetus will probably follow. 

Treatment consists in absolute rest and sedatives, such as 
morphine (gr. ^), administered every six hours. 

Placentitis. 

This term is applied to an inflammation of the substance 
of the placenta. The condition is rare. 

Pathological changes : Some authorities contend that by 
reason of the anatomical structure of the placenta a true in- 
flammation cannot occur. But it is certain that a marked 
hyperplasia of the connective-tissue cells entering into the 
formation of the placenta does sometimes occur. This fibrous 
change may originate in the decidua serotina, the placental 



164 PATHOLOGY OF PREGNANCY. 

villi or the intervillous spaces. When the clecidua serotina 
is affected the result is firm attachment of the placenta to the 
uterine wall, the so-called adherent i^lacentd. 

In the other two forms the placenta will be found to con- 
tain a number of firm fibrous masses. Occasionally the cen- 
tral portions of these masses may undergo a cheesy degenera- 
tion which appears very like pus. 

Tumors of the Placenta. 

Rarely either cystic or solid tumors of the placenta are met 
with. 

Syphilis of the Placenta. 

The syphilitic placenta is characterized by its thickness 
and density, while its general color is paler than normal. 
Scattered over its surface and through its substance are 
cherry-like nodules. There are present marked fibroid de- 
generation and great hypertrophy of the villi. 

The seat and extent of the lesions vary with the manner 
and time of the foetal infection. It is only by a microi^coplcal 
examination that a placenta can safely be pronounced syph- 
ilitic. 

(Edema of the Placenta. 

A serous infiltration of the placenta is often observed with 
a dead and macerated foetus. Interference with the foetal 
or placental circulation may also produce this condition. 

Anomalies of the Umbilical Cord. 

Length : The cord may be found abnormally long, measuring 
as much as seventy inches, or abnormally short, measuring 
only two to four inches. Anomalies of insertion of the cord 
have already been mentioned. 

Coils : The cord, if it be of unusual length, may be found 
encircling the limbs or neck of the child. It is most fre- 
quently coiled about the neck ; in extreme cases as many as 
six or eight coils may be present. In such cases asphyxia is 
common. 



I 



IDIOPATHIC DISEASES, 165 

Knots : When the liquor amnii is excessive and the cord 
unusually long it may be found to have one or two knots, 
formed by the passage of the foetus through its loops. 
Rarely this results in the death of the foetus. 

Hernia into the cord : A congenital protrusion of some of 
the abdominal viscera into the sheath of the umbilical cord is 
occasionally met with. It is due to imperfect development 
of the abdominal wall at the seat of the hernia. 



THE FCETUS. 

Anomalies and Monstrosities, 

Teratology, wliich is the science pertaining to foetal malfor- 
mations and monstrosities, forms a special branch of pathology, 
reference to which must be had elsewhere. 

Such malformations of the foetus as interfere with the 
mechanism of labor will be discussed under the headino^ of 
dystocia of foetal causation. 

DISEASES OF THE FCETUS. 

It is probable that foetal mortality exceeds that of any 
other period of life. It is impossible to say exactly what is 
the foetal death-rate, as actual statistics are wanting ; but that 
it must be very high the frequency of abortion proves. 
AVhitehead has stated that the ratio of abortions to pregnan- 
cies is 1 to 7 ; while Priestly, from a study of the miscar- 
riage-rate in the well-to-do classes, considered the ratio of 
abortions to pregnancies as about 1 in 4J. 

But a few of the more important pathological conditions 
affecting the foetus can be referred to in a limited work of 
this kind. 

Idiopathic Diseases. 

Those originating, so far as at present known, in the foetus 
itself: 

Congenital cystic elephantiasis : This disease is characterized 
by a great overgrowth of the subcutaneous connective tissue 
all over the body. At intervals in the hypertrophied tissue 



166 PATHOLOGY OF PREGNANCY. 

cysts are present, which vary greatly in size. As malforma- 
tions of a grave character are usually associated with this 
disease, the subjects of it are usually born prematurely and 
scarcely ever survive the birth. 

Anasarca : General anasarca of the foetus is occasionally 
seen. The condition is usually associated with collections of 
fluid in the pleural and abdominal cavities. The subjects of 
this disease are usually born prematurely and seldom survive. 

Ichthyosis : This disease is observed in two forms, the 
grave and the mild. 

The grave form is characterized by the existence over the 
whole surface of the body of horny epidermic plates, separated 
from each other by fissures and furrows, and associated with 
deformities of the face and extremities which lead to death 
of the infant soon after birth. 

The mild form is characterized by the presence of a col- 
lodion-like substance over the whole body of the foetus which 
later, by a process of desquamation, forms into flakes. It is 
usually associated with ectropion and eclabium. It does not, 
as a rule, prove fatal, but may persist more or less throughout 
life, or may terminate by complete cure. 

With regard to the etiology but little can be said beyond 
asserting that heredity is probably the most powerful factor. 

Treatment: Warm baths and inunctions with weak anti- 
septic ointments promote separation of the scales. Perfect 
cleanliness is necessary to prevent infection of the fissures 
existing in the skin. 

Rachitis : That this disease occasionally occurs during in- 
tra-uterine life is believed by many. Children have been 
born whose bones were still soft and easily distortable ; while 
in others, in whom the disease had probably pursued a longer 
course, the bones were thick and hard, and set in the de- 
formed shapes they had acquired in utero. The presence of 
the disease in the foetus has been held to account for those 
rare cases of spontaneous fracture in utero, in which there 
has been no history of external violence. 



FCETAL SYPHILIS. 167 

Transmitted Diseases. 
Those due to diseases in the parents : 

Foetal Syphilis. 

This is probably the most important if not the most com- 
mon disease of intra-uterine life. Page has reported that 
83 per cent, of premature and stillbirths have their cause in 
syphilis of one or both parents. 

Infection : The ovule may be diseased before impregnation, 
where the woman is a syphilitic. Infection may occur along 
with impregnation where the male is a syphilitic. The foetus 
may become infected at any, period of intra-uterine life, 
should the mother contract syphilis Avhile pregnant. When 
the infection is directly paternal in origin, the syphilitic 
poison may be conveyed from the foetus to the mother, and 
she may thus develop secondary symptoms of the disease 
without a primary lesion. It is undoubted that many women 
give birth to syphilitic offspring without themselves at any 
time manifesting symptoms of the disease. The likelihood 
of development of the disease in the foetus is undoubtedly 
aifected by the period of time since the acquisition of syphilis 
by either parent, though as yet no limit of safety has been 
discovered. The author has met with a case where the dis- 
ease had remained latent in the father for twelve years. The 
mother at no time gave evidence of syphilitic infection, yet 
the only child developed well-marked symptoms a few weeks 
after birth. Hutchinson has reported cases in which women 
were infected near term and gave birth to syphilitic infants. 

Manifestations of fcBtal syphilis : The disease produces a 
great variety of manifestations, the lesions depending upon 
the tissues attacked. Thus there are bullous eruptions of the 
skin ; inflammations of mucous and serous membranes ; 
abnormal development of connective tissue in the liver, 
kidneys, lungs, spleen, etc ; and a characteristic osteitis and 
osteochondritis. In some cases the infants are born appar- 
ently healthy and only manifest symptoms of the disease 
within a few weeks of birth. 

Diagnosis : Should the foetus be born dead the diagnosis can 



168 PATHOLOGY OF PREGNANCY. 

be made with certainty by a few perfectly reliable and easily 
detected signs. 

The most certain sign of foetal syphilis is to be found in the 
condition of the dividing line between the diaphysis and epiph- 
ysis of the long bones — this line instead of being sharp 
and regular as it is in the healthy infant, will be found to be 
jagged, broad, and of a yellow color, due to an osteochondri- 
tis. This is known as Wagner^s sign and is determined by 
making an incision over the trochanter as though for excision 
of the head of the femur ; the end of the bone is then turned 
out after cutting its ligaments, and a median section of the 
epiphysis and diaphysis is made with a strong cartilage knife. 

The liver and spleen of a syphilitic infant are always 
enlarged as a result of connective-tissue overgrowth. For a 
more detailed diagnosis of syphilis in the infant the reader 
is referred to other works. 

The treatment of foetal syphilis consists in submitting the 
mother to a thorough course of antisyphilitic treatment 
throughout pregnancy. If a history of syphilis in either 
parent be obtained, whether occurring before or subsequent to 
conception, the woman should receive throughout the preg- 
nancy antisyphilitic treatment as a prophylactic measure. 

Other Infectious Diseases. 

A large number of cases have been collected by various 
observers which prove the possibility of contagious diseases 
being transmitted from the mother to the foetus in utero. 
Rare cases are recorded where children have been born with 
unmistakable evidences of variola, scarlatina, measles, ery- 
sipelas, malaria, and typhoid. 

AVith regard to tuberculosis Hirst states that there is a 
remote possibility of the passage of the tubercle bacilli from 
mother to foetus; but that it must be regarded as a very 
exceptional occurrence. 

Foetal Death. 

The death of the foetus in utero may be due to many causes. 
Among these may be mentioned syphilis, acute infectious dis- 



THE VULVA AND VAGINA. 169 

eases, icterus gravidarum, malnutrition, etc. It is also caused 
by twisting or knotting of the cord, diseased conditions of 
the placenta, or by trauma. 

Sequelae : If death occur before the second month the 
product of conception may be entirely absorbed. In the later 
months of pregnancy the foetus may undergo maceration, 
mummification or calcification. Should putrefaction of the 
dead foetus occur, the mother may be involyed in sepsis. The 
dead foetus is usually cast out of the uterus in a short time, 
though it may be retained for years. 

PATHOLOGY OF THE PREGNANT WOMAN. 

The Vulva and Vagina. 

Abnormal conditions of the vulva or yagina during preg- 
nancy are generally due either to increased blood-supply or 
to infection. 

Varices : Obstruction to the yenous return offered by the 
enlarging uterus frequently results in yaricosed conditions 
about the yulva or yagina; these varices may be ruptured 
by straining or by a blow or kick; severe hemorrhage may 
occur and has proved fatal. 

Treatment consists in protection by means of a snugly 
fitting T-bandage, and rest in bed with the hips elevated. 

(Edema may occur in normal pregnancy simply from pres- 
sure of the uterus. It may result from renal insufficiency or 
from labial abscess. 

Pruritus of the yulya in varying degrees is not uncommon 
during pregnancy. It may be caused by irritating discharges 
or may be a neurosis. 

Treatment: Cleanliness and tepid injections of such solu- 
tions as the following : borax, 3j to Oj ; acid, carbolic, 1 : 200 ; 
or zinci acetat., oSS to Oj ; an ointment composed of chloral 
hydrate, camphor, aa 5ss, ung. aq. rosse, sij, may give relief. 
In severe cases it may be necessary to apply solutions of 
cocaine, 4 grains to the ounce, in order to obtain any relief. 

Vaginal leucorrhoea may be very troublesome during preg- 
nancy. In all cases where the discharge is profuse it should 
be examined for gonococci. Simple leucorrhoea usually yields 



170 PATHOLOGY OF PREGNANCY. 

to mild antiseptic astringent douches which shoidd be given 
with great care, e.g., Condy's fluid, .^j to Oj. 

Should gonococcl be found in the vaginal discharge the 
treatment should be energetic : bichloride (1 : 2000) or perman- 
ganate of potassium (sj to Oj) douches should be given twice 
daily, and an occasional application to the walls of the vagina 
and urethra of a solution of silver nitrate (gr. x-xx to 5j) will 
probably give good results. 

Vegetations of the vulva sometimes reach excessive size dur- 
ing pregnancy. The treatment consists in washing with liquor 
sodse chlorinatse, afterward dusting with calomel, and keeping 
them perfectly dry. 

The Uterus. 

This organ may in pregnancy be displaced forward, back- 
ward, to either side, or downward. 

Retroversion of the Gravid Uterus. 

Causation : The displacement is of frequent occurrence and 
may have existed before the onset of pregnancy ; or it may 
occur as the result of a fall or sudden jar. 

Anatomical results : As long as the uterus is less than four 
inches in length it may lie across the axis of the pelvis. As 
its bulk and length increases, it becomes too large for the pel- 
vis. If upward movement be prevented by the projecting 
promontory incarceration occurs, and pressure symptoms 
l)egin to develop. Incarceration usually occurs about the end 
of the third or the beginning of the fourth month. The dis- 
tended fundus will on examination be found to occupy the 
hollow of the sacrum causing a bulging downward of the pos- 
terior vaginal wall, while the cervix is pressed upward and 
forward against the pubes, thus displacing the anterior vag- 
inal wall and urethra. The bladder is thus displaced upward. 
The uterus may regain its normal position by growing upward 
in the direction of least resistance ; or it may remain incar- 
cerated and give rise to serious trouble. 

Symptoms : The earliest and most distinctive symptom is 
dysuria, accompanied by sensations of weight and bearing- 



TREATMENT OF RETROVERSION. 171 

down pains. If the condition be overlooked or neglected the 
bladder symptoms become rapidly more marked. Retention 
of urine from pressure on the urethra brings about overdis- 
tention of the bladder, and a more or less severe cystitis 
results. 

While the urinary symptoms are the most characteristic, 
the condition also gives rise to rectal tenesmus and obstinate 
constipation. OEdema of the vulva and of the uterine walls 
may develop from interference with the pelvic circulation. 
The abdomen becomes distended and vomiting may occur. 

Diagnosis : Where the retroversion is suspected the bladder 
must first be catheterized before making a vaginal examina- 
tion. The condition will then be readily ascertained. 

The history of retention of urine and dribbling in a woman 
who has been pregnant for three or four months, the round 
doughy-feeling mass occupying the vagina, and the position 
of the cervix make the diagnosis conclusive. 

The condition may be simulated by ectopic gestation, sub- 
involution of the uterus, intraperitoneal hsematocele, uterine 
fibroid, and ovarian cyst ; but careful examination, if neces- 
sary, under an anaesthetic, will clear up the diagnosis. 

Treatment of Retroversion. 

In mild cases the bladder having been catheterized and the 
patient placed in the knee-chest position, the uterus can be 
replaced by pressure upward on the fundus in the direction 
of one or the other sacro-iliac joints, so as to avoid the 
])romontory, two fingers being placed in the posterior vaginal 
fornix for this purpose. If necessary the cervix may at the 
same time be drawn down with a tenaculum. If the attempt 
succeeds, as it usually does, a large tampon should be placed 
in the posterior vaginal fornix to retain the uterus in position. 
This may be replaced later by a large-sized pessary. If the 
attempt fails, the patient should be placed under ether and a 
second effort made to replace the uterus. 

In severe incarcerated cases there is occasionally great dif- 
ficulty in emptying the bladder. If, after drawing down the 
cervix with a tenaculum, the catheter fails to pass, then the 
bladder must be aspirated by suprapubic puncture. If all 



172 PATHOLOGY OF PREGNANCY. 

attempts at reduction fail, then abortion must be induced. If 
the cervix cannot be reached for this purpose then the uterine 
wall must be punctured through the vaginal vault and the 
liquor amnii drained away. This may make it possible to 
draw down the cervix, which should then be dilated and the 
uterus emptied. Vaginal hysterectomy may be necessary in 
rare cases where suppuration or gangrene of the uterine wall 
has occurred. 

Prolapse of the Gravid Uterus. 

Causation : This condition may occur in the early months 
of pregnancy as the result of accident or from violent strain- 
ing when the vaginal walls and outlet are greatly relaxed. 

Treatment consists in the replacement of the prolapsed 
organ and the adjustment of a perfectly fitting pessary to 
retain it. 

Endocervicitis ; Tumors. 

Endocervicitis : This condition is frequently found during 
pregnancy. It may be the origin of a leucorrhoea and is fre- 
quently associated with hyperemesis. 

It is best treated with applications of fairly strong solutions 
of silver nitrate (gr. xx to 5j) through a cylindrical speculum. 
The speculum is pushed up against the cervix and the solu- 
tion then poured in and allowed to remain in contact for at 
least five minutes. 

Uterine fibroids and cancer usually complicate labor more 
than pregnancy, and will therefore be dealt with under that 
head. 

Diseases of the Breasts. 

Mammary abscess may occur during pregnancy (see Diseases 
of Puerperal Period). 

Excessive secretion : Occasionally during the latter part of 
pregnancy the breasts secrete excessively, causing a serous 
flow which gives rise to considerable inconvenience. Appli-* 
cations of belladonna may afford relief. 

Eczema of the nipples may require treatment, though the 
condition is very obstinate. 



PTYALISM, OB SALIVATION. 173 



DISEASES OF THE ALIMENTARY CANAL. 

Gingivitis is an unpleasant though somewhat infrequent 
affection of the pregnant woman. This and other conditions 
about to be mentioned" are due, not so mucli to uncleanliness, 
as to an alteration in the secretions of the buccal cavity con- 
sequent upon pregnancy. The gums become spongy and soft, 
red or violet in color at the margins, and occasionally ulcera- 
tion occurs. Pain on eating, foul breath, and bleeding are 
symptoms of this condition. 

Treatment: Sometimes gingivitis is very obstinate and in 
spite of treatment persists through pregnancy and even lacta- 
tion. Astringents, locally, and alkaline tonics give the best 
results. Special attention in the Avay of cleanliness as regards 
the mouth and teeth should be observed throughout preg- 
nancy. 

Dental caries: There is a common saying among women, 
" for every child a tooth, '^ so frequent is caries of the teeth 
during pregnancy. All dental cavities should be cleaned 
out and filled temporarily, as prolonged and ])ainful dental 
operations are to be avoided during pregnancy. Syrup of 
the lactophosphate of lime in doses of 3J t. i. d. has been 
recommended. 

Parotitis, either unilateral or bilateral, is an infrequent com- 
plication of pregnancy. 

Ptyalism, or Salivation. 

Occurrence : This is a not infrequent complication of preg- 
nancy. It is generally associated with extreme nausea and 
vomiting in highly neurotic women. It may persist through- 
out pregnancy, beginning as early as the second month ; 
some cases lose as much as a quart of "saliva a day. Ptyalin, 
and sodium salts are diminished or may be absent from the 
saliva. Frequently these patients complain of pain on swal- 
lowing; and the submaxillary and sublingual glands become 
swollen and tender. 

Treatment is most unsatisfactory in most cases. Copious 
rinsing of the mouth with weak solutions of potassium chlor- 
ate, ash bark, cinchona, etc., may be employed. In the ex- 



174 PATHOLOGY OF PREGNANCY. 

perience of the author, local measures afford but little if any 
relief. The (X)n(lition is a neurosis and must be treated as 
such. Therefore chloral and sodium bromide in large doses 
may be tried ; atropine in doses of gr. j^q- t. i. d. may give re- 
lief. What rarely fails to give temporary relief is morphine 
(gr. \) with atropine (gr. y^-Q^), tliese administered together 
give better results than either alone. The latter must not 
be given as routine treatment, but only occasionally to permit 
rest and sleep, while the patient should always be kept in 
ignorance of what she is given in order to guard against the 
formation of the morphine habit. Antipyrin (gr. v, t. i. d.) 
and small doses of cocaine hydrochlorate (gr. i, t. i. d.) have 
proved useful in the hands of some physicians. 

Indigestion; Constipation; Diarrhoea. 

Indigestion : Gastric indigestion is very common in the 
earliest months of pregnancy. If careful feeding and the 
ordinary remedies fail to give relief, chloral, bromides, and 
other nerve sedatives should be resorted to. Intestinal in- 
digestion may give rise to severe abdominal pains and may 
simulate appendicitis or even extra-uterine foetation. Pil, 
aloes et asafoetid^ and careful dieting, as a rule, give good 
results. 

Constipation is very frequent in most women at all times. 
Care should be taken to regulate the bowels by careful diet- 
ing and ordering plenty of fluids. Where this condition is 
chronic the tablet triturate of aloin, belladonna, cascara, and 
strychnine will be found satisfactory; active purgation is to 
be avoided. 

Diarrhoea as a complication of pregnancy is rare ; if persist- 
ent in spite of ordinary astringent treatment, nerve sedatives 
will probably give relief. 

Vomiting. 

Vomiting is one of the commonest disorders of the digestive 
tract occurring in pregnancy. 

It is met with in two forms : A simple, vomiting, which is 
physiological ; and pernicious vomiting, which is pathological. 



PERNICIOUS VOMITING OF PREGNANCY. 175 

Simple vomiting of pregnancy lias been already referred to. 
It is usually present during the earlier months and ceases at 
the end of the fifth month. AVhile causing distress and dis- 
comfort it does not seriously impair the nutrition of preg- 
nant women. 

Pernicious Vomiting of Pregnancy. 

This, on the other hand, is a very serious condition, which 
may, if it resist treatment, p^ace the woman's life in jeopardy. 

Symptoms : This uncontrollable form of vomiting rarely 
begins abruptly, the vomiting, Avhich is at first mild, becoming 
gradually more severe and almost constant. Ultimately ab- 
solutely nothing can be retained, and the patient rapidly loses 
strength. At first the vomited matter consists of thick mucus, 
particles of food, and bile ; later only blood- stained mucus is 
ejected, and the retching becomes more severe, e])igastric pain 
develops, and there is great aversion to food. Ptyalism and 
diarrhoea are not infrequent at this stage. The patient rapidly 
loses strength, becomes mentally depressed, and suffers more 
or less constant pain. 

If the condition is not relieved the temperature rises and 
the patient develops symptoms of auto-intoxication. The 
temperature may range from 101° to 103° F. and the pulse 
from 120 to 140; the extremities become cold and the skin 
moist and clammy ; the mouth becomes dry and the patient 
complains of intense thirst; sordes appear on the teeth, the 
tongue becomes coated with a heavy brown fur, and the 
breath is extremely offensive. The urine becomes scanty, 
high colored and offensive, its specific gravity is high, and 
it contains albumin and casts. 

Emaciation advances rapidly and the patient's condition 
soon becomes serious in the extreme. Cerebral symptoms, 
hallucinations, delirium, and finally coma develop shortly 
before death closes the scene. 

The duration of the malady is two or three months, but 
its course is subject to intermissions the cause of which is 
hard to explain. The symptoms may disappear for several 
days and the patient give evidence of improvement, when 
suddenly they recur, only too often with increased severity. 



176 PATHOLOGY OF PREGNANCY. 

The etiology of pernicious vomiting is very obscure. So 
many factors may contribute to the production of this con- 
dition that just what is the cause in any definite case can 
rarely be stated. Giles has pointed out that probably three 
factors enter into the causation of the physiological vomiting 
of pregnancy, namely (1) exalted nerve tension; (2) periph- 
eral nervous irritation arising from the enlarging uterus ; and 
(3) an easy outlet for this exalted tension, namely, the vagus. 

By the exaggeration of any one or two of these factors 
pernicious vomiting may be produced. Bearing these three 
factors in mind, the predisposing causes of pernicious vomit- 
ing may be grouped as follows : 

(a) Primiparity. In primiparse the distention of the womb 
is accomplished with increased difficulty on account of the 
greater tonicity of the uterine muscular fibres. 

(6) Preexisting disease of the uterus, as metritis or endo- 
metritis, or displacements of the organ. 

(c) Disease of other pelvic structures, either preexisting or 
coexisting, as salpingitis, ovaritis, etc. 

{(1) Pathological states of the alimentary canal, as gastric 
ulcer, dyspepsia, gastritis, etc. 

(e) Too frequent sexual intercourse. 

(/) Mental or physical shocks. 

(j7) Toxic conditions of the blood, uraemia, saprsemia, etc. 

Recently I have advanced the view that probably the essen- 
tial exciting cause of the nausea and vomiting of pregnancy 
is the physiological uterine contractions. It is well known 
that the uterus is subject to rhythmical contractions through- 
out the whole period of pregnancy. The purpose of these 
contractions is probably the acceleration of the circulation of 
blood through the uterine sinuses. The enormous dilatation 
of the veins of the uterus which occurs as the result of preg- 
nancy brings about a retardation of the blood flow through 
them. As the result of contraction of the uterine muscular 
fibres these sinuses become emptied of blood and thus the 
uterus may be said to supplement the action of the heart, to 
which it may be compared, as its nervous supply is very simi- 
lar in arrangement. The nerve supply of the uterus is chiefly 
derived from the ovarian and hypogastric plexuses of the 



PERNICIOUS VOMITING OF PREGNANCY. 177 

sympathetic system, which to a limited extent have an inde- 
pendent action ; while in the medulla there exists a centre 
presiding over uterine contraction. The development of the 
embryo and its envelopes, as well as the hyperplasia of the 
uterus and its lining, are accompanied by tremendous chemi- 
cal changes. It is certainly from the venous sinuses at the 
placental site that the embryo derives its chief nourishment 
and into which its effete material is emptied. The ordinary 
circulation of the blood through the sinuses to a certain extent 
provides for change in the supply, but owing to the retardation 
of the blood-current from dilatation of these sinuses there 
must be a certain residuum, which, as it becomes surcharged 
wdth effete material, probably acts as an irritant and stimu- 
lates the uterus to contraction, and thus to a certain degree 
the organ may be said to empty itself. 

It is these contractions, so brought about, which probably 
precipitate the paroxysms of nausea and vomiting. The 
nausea is seldom constant, but is usually rhythmical in its 
occurrence. As has already been stated it is usually most 
severe in the morning when after a long fast the patient as- 
sumes the erect position. It is probable that the occurrence 
of the retching at this time is due to the engorgement of the 
pelvic circulation consequent on the change of posture. This 
engorgement leads to excessive uterine contraction, and thus 
the peripheral irritation is increased. It is commonly noticed 
that if the patient partakes of food before rising nausea and 
vomiting are not so likely to ensue. This is due no doubt to 
the engorgement of the pelvic veins being reduced by the 
determination of blood to the stomach from the presence of 
the food in that viscus. 

The causes mentioned in the foregoing table as predisposing 
to pernicious vomiting probably act by increasing the tendency 
to contraction on the part of the uterus (too frequent inter- 
course ; nervous shocks and toxic conditions) ; or by render- 
ing them more difficult and therefore increasing the irritation 
they cause (primiparity ; metritis, and disease of neighboring 
structures). 

The prognosis should be guarded in all cases, as the mortality 
ranges from 30 to 60 per cent, in the pernicious form. 

12— Obst. 



178 PATHOLOGY OF PREGNANCY. 



Pernicious Vomiting — Treatment. 

Dietetic and hygienic : The diet should be light and easily 
digestible ; before rising in the morning the patient should 
take a glass of iced milk or some hot clear coifee or weak 
tea. In some cases a glass of sherry and a dry biscuit answer 
the purpose very well. 

It is a good plan to order small quantities of plain food at 
two-hour intervals during the day, instead of allowing the 
patient three regular meals. If the nausea be troublesome 
the patient should be kept reclining as much as possible, 
when the weather permits, out in the open air. Close, warm 
rooms and tight clothing should be avoided, and attention 
should be given to the condition of the bowels. When vom- 
iting occurs only in the morning such measures will enable 
the patient to pass the day in comparative comfort. 

When vomiting takes place several times a day, some simple 
sedative mixture should be ordered, such as the following : 

I^. Sod. brom., gr. xv ; 

Aq. camphorse, ^ss. — M. 

Sig. t. i. d. 

Effervescent bromocaffeine in drachm doses three or four times 
daily often renders good service. Iodine or carbolic acid in 
minim doses, well diluted, may be tried. 

Patients who do not yield to the above treatment should be 
confined to bed. A thorough examination should be made to 
ascertain if any of the pathological conditions above enumer- 
ated as predisposing to hyperemesis gravidarum are present, 
and if so appropriate treatment should be inaugurated. 

Where nothing can be discovered to account for the con- 
dition beyond pregnancy, the stomach should be given a 
rest and rectal alimentation resorted to. Predigested milk 
and eggs, nutrient broths, and beef peptonoids may be ad- 
ministered per rectum every six hours. 

The rectum should be washed out at least twice daily, and 
immediately afterward a pint of normal saline solution should 
be introduced by means of a catheter attached to the nozzle 
of the syringe, high up into the bowel, in order to relieve the 



ICTERUS. 179 

troublesome thirst which is usually present in these cases. 
The nutrient enemata should be given very slowly, and should 
never consist of more than five or six ounces. Twice daily 
an enema containing chloral hydrate, (gr. xx) and sod. brom. 
(gr. xl) in 6 ounces of milk should be given. Cold packs to 
the spine or the application of a spray of ether in the region 
of the fourth or fifth dorsal vertebra may prove of benefit. 

Xearly every drug in the pharmacopoeia has been recom- 
mended as a specific in this condition. The following have 
been employed with success by many : antipyrin, gr. v, t. i. d. ; 
trional, gr. xv, b. i. d. ; cocain, gr. \ hourly till five doses have 
been taken ; ac. hydrocyanic, dil., TTLiij in carbonated w^ater 
aft^r food ; and vin. ipecac, in half-minim doses every hour 
for several doses. The application of 4 per cent, solution of 
cocaine to the cervix has been recommended very highly. The 
application of solutions of nitrate of silver, gr. xx-xl to the 
ounce, after the manner recommended in the treatment of 
endocervicitis, has many advocates. 

Copeman first recommended digital dilatation of the cervix 
in the treatment of this condition. Cervical dilatation is more 
conveniently done by means of instruments, either Hegar's or 
Goodell's ; but care must be taken not to rupture the mem- 
branes. This treatment is uncertain, and is therefore not to be 
recommended. 

In rare cases it is necessary to induce abortion in order to 
save the patient's life. It is a difficult question to decide just 
when one is justified in terminating the pregnancy. If rectal 
alimentation fails after a fair trial and the patient is absohitely 
unable to retain anything on the stomach ; if the pulse rises 
to 120 and prostration becomes marked, then the sooner the 
uterus is emptied the better. 

This procedure should never be adopted Avithout the sup- 
port of a competent consultant. 

Icterus. 

Jaundice is occasionally met with in pregnancy. It may 
result from gastro-intestinal catarrh, from phosphorus-poison- 
ing, or from obstruction of the bile-duct due to the pressure 
of an overdistended uterus. The development of gall-stones 



180 PATHOLOGY OF PREGNANCY. 

in pregnancy is of somewhat frequent occurrence. A severe 
form, icterus gravis gravidarum^ is of very rare occurrence. It 
is nearly always fatal, and is due to an acute degeneration of 
the whole hepatic structure. Acute degeneration of the liver 
and icterus are not infrequent in eclamptic cases. 

Icterus endangers to a high degree the life of the foetus, by 
bringing on abortion or by the injurious action of the bile 
salts. Not infrequently the liquor amnii and fcetus are stained 
by the coloring-matter of the bile. 

Treatment : In mild cases, warm alkaline baths and calomel 
associated with mild purgative waters are indicated. In very 
severe cases the induction of abortion should be considered, 
especially if the foetus is viable. 

Hemorrhoids. 

The pelvic congestion of pregnancy and the pressure of the 
gravid uterus predispose to this troublesome affection. 

Treatment can only be palliative. Laxatives, rest in bed, 
and the frequent assumption of the knee- chest posture will 
afford relief. Locally, ung. gallse cum opio, or hot sugar of 
lead lotions, may be serviceable. Suppositories containing 
opium (gr. |) and ext. hamamelidis (gr.j) may be employed 
if the pain is severe. 

DISEASES OF THE URINARY SYSTEM. 

The Bladder. 

Irritability of the bladder is a frequent functional disorder 
of pregnancy. It is generally relieved by the administration 
of alkaline sedative mixtures. 

Hsematuria may occur during pregnancy, and is generally 
associated with vesical hemorrhoids. If severe, the bladder 
should be washed out daily with a weak solution of silver 
nitrate (gr. ss-j to .Ij). 

Scanty, high-colored urine having a high specific gravity, 
results from indiscretion in diet, and is associated with inactiv- 
ity of the skin and bowels ; this condition of the urine should 
always receive attention. A non-nitrogenous diet, laxatives, 
and copious draughts of water should be ordered. 



THE KIDNEYS. 181 

Albuminuria is found in from 5 to 6 per cent, of pregnant 
women, and is usually associated with kidney-changes due to 
pregnancy, or nephritis. 

The Kidneys. 

Kidney of pregnancy: There exists undoubtedly a chronic 
form of renal disease which is dependent on pregnancy, and 
which, as a rule, does not give rise to serious disturbance of the 
patient's general health. It is usually associated with albu- 
minuria and subsides rapidly after parturition. It is impor- 
tant, as it predisposes to the development of the condition of 
eclampsia, in so far as it interferes with the proper function of 
these important excretory organs. 

Frequency : As already stated, albuminuria is present in from 
5 to 6 per cent, of all cases of pregnancy ; but it is probable 
that a far larger proportion of cases have some degree of renal 
insufficiency, though albumin may not be present in the 
urine. 

Pathology : The kidneys are usually anaemic, and present 
evidences of fatty infiltration of the epithelial cells w^ithout 
inflammatory changes. 

Symptoms : The condition is not infrequently met with in 
primiparse. The symptoms usually manifest themselves in 
the latter half of the pregnancy, and are generally mild. 
Headache, pallor, weakness, and slight shortness of breath 
are usually the only subjective manifestations. The urine is 
lessened in quantity, is clear, and its specific gravity is re- 
duced ; it contains from a quarter to one-half its bulk of 
albumin, and a few granular casts ; the albumin is mainly 
paraglobulin. The urea daily excreted is generally below 
the average of health ; generally the lower the index of urea 
the more marked are the patient's symptoms. Delivery is 
followed by diuresis, which is most marked from the third to 
the fifth day. 

Etiology : The cause of the condition is probably a diminu- 
tion of the blood-supply due to increased intra-abdominal 
tension ; and to irritation from the excess of effete substances 
contained in the maternal blood. 

Treatment is as that for true nephritis. 



182 



PATHOLOGY OF PREGNANCY. 



Acute and Chronic Nepliritis. 

These diseases are more prone to occur during pregnancy 
on account of the extra amount of work devolving upon the 
kidneys at this period. 

The symptoms are the same as in cases not complicated by 
pregnancy. 

Differential diagnosis : It is not always easy to differentiate 
between the kidney of pregnancy and chronic nephritis ; but 
the following differential signs may prove of aid : 



History. 


Kidney of Pregnancy. 


Chronic Nephritis. 




Kidneys normal before 


Existed before preg- 




pregnancy. 


nancy. 


Quantity of urine. 


About normal or slightly 
lessened. 


Increased. 


Specific gravity. 


Low. 


Low. 


Casts. 


Few and only with severe 


Numerous and appear 




symptoms. 


early in pregnancy. 


Ketinitis. 


Absent. 


Very often present. 


Grave symptoms. 


Generally appear in later 


May be pronounced 




months of pregnancy. 


in early months. 




Ceases with parturition. 


Persists after parturi- 
tion. 



Prognosis : The possibility of complications renders the 
prognosis for the mother doubtful, while as regards the child 
it is decidedly grave on account of the tendency to the forma- 
tion of placental infarctions. Premature interruption of the 
pregnancy is also of frequent occurrence. 

Treatment : As it is important to know the condition of the 
kidneys in pregnancy, frequent examinations of the urine 
should be made. Should evidences of renal insufficiency 
present themselves, the patient should at once be placed upon 
a dietetic and hygienic regimen. Meat should be excluded, 
and the diet consist of milk and farinaceous foods ; large 
draughts of water, preferably Poland or lithia water, should 
be systematically taken. The patient should be guarded 
against fatigue and exposure to cold or dampness. A saline 
laxative should be administered two or three times a week. 



DISEASES OF THE RESPIRATORY SYSTEM. 183 

Should the quantity of the urine excreted not increase, and 
oedema appear, the patient should then be placed on an ex- 
clusively milk diet and be put to bed ; a diuretic mixture 
should be ordered, such as Basham's mist, ferri et ammon. 
acetatis, U. S. P., in 3ss doses after meals. 

If under tliis treatment the symptoms grow gradually 
worse, then the termination of pregnancy is necessary. When 
albuminuric retinitis develops, abortion must at once be in- 
duced if the patient's life is to be saved, hence the importance 
of an ophthalmoscopic examination in all cases in which ob- 
scurity of vision is a symptom. 

DISEASES OF THE EESPIRATORY SYSTEM. 

Cough, with or without evidence of bronchial catarrh, is a 
very common and occasionally troublesome affection during 
pregnancy. The reflex cough of pregnancy may be very 
persistent, and when the paroxysms are severe and continuous 
may lead to abortion. In its treatment antispasmodics and 
sedatives are indicated rather than expectorants. Bromide 
of sodium and tr. belladonnse in combination give good results, 
as do also drachm doses of the linctus codeia. 

Dyspnoea occasionally occurs as a reflex, and may cause the 
patient considerable distress. It is more frequent in the 
later months of pregnancy, when it is generally due to over- 
distention of the abdomen and mechanical pressure of the 
uterus upon the diaphragm. In the former class of cases 
sedatives are indicated ; while in the latter relief may be ob- 
tained by avoiding tight clothing, and having the patient 
sleep with the head and shoulders elevated. 

Pneumonia is a disease much to be dreaded when complicated 
by pregnancy. The symptoms are always aggravated and the 
mortality for both mother and foetus is high. 

Phthisis pulmonalis : Pregnancy has a most unfavorable in- 
fluence on this disease. Rarely, patients suffering from phth- 
isis seem to improve during pregnancy ; but the disease only 
advances the more rapidly after delivery has occurred. 



184 PATHOLOGY OF PREGNANCY. 

Women already affected and predisposed to tuberculosis 
should be strongly advised against maternity. 

DISEASES OF THE CIRCULATORY SYSTEM. 

Cardiac diseases in pregnancy are not rare ; the danger of 
the heart lesions is increased by pregnancy ; abortion is apt 
to occur from the formation of infarctions in the placenta ; 
not infrequently the child is born badly nourished. 

The GompUcations to be dreaded are failure of compensation 
due to fatty degeneration ; and pulmonary congestion. If 
compensation is good, no untoAvard symptoms are likely to 
develop, beyond oedema and albuminuria, the latter being 
due to renal congestion. Hirst states that with proper treat- 
ment he has no fear of heart disease in pregnancy. 

Treatment: All women suffering from cardiac disease 
should be kept under constant observation throughout gesta- 
tion. The urine should be frequently examined. Should 
symptoms of failure of compensation arise, digitalis and 
strophanthus should be exhibited, combined with strychnine ; 
the bowels should be kept open, and rest and moderate ex- 
ercise ordered. 

Hirst states that pregnancy should not be allowed to con- 
tinue longer than the thirty-sixth week ia a woman who ex- 
hibits any symptoms of imperfect compensation. Cardiac 
diseases do not contraindicate the employment of anaesthetics 
during labor. These benefit by preventing the injurious effects 
of straining and by quieting the action of the heart during 
parturition. 

Functional heart-murmurs in pregnancy : In the later months 
of pregnancy soft, blowing murmurs can occasionally be heard, 
both over the mitral and aortic areas ; these are usually sys- 
tolic in rhythm, but may also be diastolic. They may be 
explained by the hydrsemic state of the blood in pregnancy, 
and may in part be due to a certain amount of displacement 
of the organ resulting from overdistention of the abdomen. 
They disappear completely shortly after labor. 

The bloodvessels : Varicose conditions of the veins of the 



NEUROSES. 185 

pelvis, abdominal walls, and lower limbs are frequent during 
pregnancy. They result in part from changes in the vessels 
themselves, and in part from the mechanical obstruction to 
the circulation offered by the increasing bulk of the uterus. 
Treatment consists of elastic support where this is possible, 
and in the avoidance of constipation. 

Enlargement of the thyroid gland : The fact that there exists 
a peculiar relationship between the thyroid gland and the 
uterus and general circulation is well known. Usually a 
sympathetic growth of this gland occurs at the same time as 
enlargement of the uterus ; hence the fulness of the neck so 
often noticed in pregnant women. Thus in simple and in 
exophthalmic goitre pregnancy exerts a very unfavorable 
influence. The growtli of the gland may progress to such a 
degree as to cause pressure upon the trachea resulting in dysp- 
noea, and even threatening maternal death from asphyxia. In 
rare cases tracheotomy has been resorted to in order to save 
the patient^s life. 



DISEASES OF THE NERVOUS SYSTEM. 

Neuralgia in various portions of the body is a frequent af- 
fection of the pregnant woman. The most common situations 
are the head, hands, face, teeth, and breasts. Pelvic neuralgia 
is usually due to pressure of the growing uterus upon the 
pelvic nerves ; occasionally neuralgia occurs in the uterus. 

In the treatment of these troublesome neuralgias, tonics con- 
taining iron, quinine, and arsenic are particularly valuable. 
Attention should always be paid to the matter of diet, sleep, 
and the state of the emunctories in these cases. Any of the 
coal-tar derivatives, combined with the citrate of caffeine to 
prevent depression, usually promptly relieve the severe pain. 
All sources of local irritation should be sought for and re- 
moved. 

Neuroses. 

Chorea : Mild grades of chorea cannot be said to be uncom- 
mon in pregnancy. Chorea is more common in primiparse. 



186 PATHOLOGY OF PREGNANCY. 

Rheumatism, chlorosis, heredity, and the previous occurrence 
of the disease in childhood are considered as predisposing 
causes. It usually appears early in pregnancy and is apt to 
persist throughout its course. As a rule, in the milder cases 
it does not manifest itself during sleep. In the grave form 
it may result in the patient's death, after causing premature 
expulsion of the ovum. 

The treatment is the same as when not complicated by preg- 
nancy. 

Epilepsy is a rare complication of pregnancy. It does not, 
as a rule, exert an unfavorable influence upon the course of 
gestation, and it can usually be controlled by the free admin- 
istration of potassium iodide. 

Hysteria is frequent during pregnancy. 

Vomiting and coughing occur as neuroses during pregnancy, 
and have already been referred to. 

Psychical disturbances : Not uncommonly a complete change 
in the disposition and mental character of the woman may 
occur during pregnancy. 

Insomnia may be troublesome toward the close of pregnancy. 
A warm bath on retiring, a glass of milk, or a cup of warm 
broth, taken at the same hour, may be sufficient to induce 
sleep; sulphonal or trional in 10- to 15-grain doses may be 
resorted to if required. 

Insanity is of but rare occurrence during gestation, being 
much more likely to develop during the puerperal period. 
Melancholia and mania are the more usual forms, the former 
being more frequent. 

The prognosis in the maniacal form is more grave than in 
the melancholic. Insanity may recur in successive preg- 
nancies. It may be stated that gravidity exerts usually an 
unfavorable influence upon insanity. 

The treatment can only be expectant and symptomatic ; in- 
duction of labor, when marked symptoms have developed, only 
tends to aggravate the condition. 

Temporary delirium may occur during labor, and is far from 
common. A woman rendered delirious from acute suffering 
in labor may do serious injury to her child, for which she 
cannot be held responsible. 



INFECTIOUS DISEASES. 187 

DISEASES OF THE CUTANEOUS SYSTEM. 

Herpes gestationis is a peculiar neurotic skin aiFection usu- 
ally met ^vith in early pregnancy. It generally persists 
throughout gestation in spite of treatment. The eruption is 
multiform, exhibiting erythema vesicles and bullae. Its treat- 
ment consists in the administration of nerve sedatives and the 
regulation of the diet and mode of life of the patient. 

Impetigo herpetiformis is rare. It usually occurs toward the 
close of pregnancy. It generally locates itself in the folds 
of the body around the groins, the umbilicus and axillae, and 
under the mammae. It occurs as small pustules forming 
crusts ; it tends to spread rapidly and may cover the whole 
body. It is generally accompanied by marked symptoms of 
systemic disturbance, high fever, chills, vomiting, and severe 
prostration. Hirst states that of twelve cases ten terminated 
fatally. The disease did not terminate gestation prior to the 
maternal death. 

The treatment is symptomatic, with the application of sooth- 
ing remedies locally. 

Pruritus is usually a local aifection limited to the vulva ; 
but it may occur as a general affection. It may cause intense 
suffering to the patient, and cases have been reported in which 
it was necessary to induce labor in order to relieve the patient. 

Treatment consists in alkaline baths (5 ounces of bicarbonate 
of sodium to the bath), and frictions with sedative lotions, as 
the camphor or chloroform liniment. Usually this treatment 
must be combined with the internal administration of chloral 
and bromide. 

Exaggerated pigmentation : Dark spots of pigmentation may 
appear on the breasts, thighs, and abdomen, and occasionally 
on the face. The condition is not amenable to treatment, and 
usually disappears shortly after labor. 

Infectious Diseases. 

Certain of the infectious diseases are more prone to attack 
the pregnant woman than are others. 

Variola is probably the most virulent of the infectious dis- 
eases attacking the pregnant woman. It generally results 
speedily in both foetal and maternal death. 



188 PATHOLOGY OF PREGNANCY. 

Scarlatina is apt to be exceedingly virulent, but it is more 
prone to attack the puerperal woman. 

Measles in the pregnant woman usually assumes a severe 
type and generally leads to abortion. The patient exhibits a 
marked tendency to develop pneumonia as a complication. 

Typhoid fever does not, as a rule, tend to assume an unusually 
severe type when it attacks the pregnant woman. The pro- 
longed elevation of temperature tends to bring about abortion. 

TOXAEMIA— ECLAMPSIA. 

Definition : Eclampsia is a disorder of pregnancy character- 
ized by epileptiform convulsions, and depending upon the 
retention within the body of toxins. The term is derived 
from the Greek ixXa/Kft^, a shining forth. The convulsive 
seizures may occur during pregnancy, labor, or the puerperal 
period, though they are most frequently associated with labor. 

Frequency : It occurs about once in 300 cases of pregnancy. 
It is more frequently met with in primiparse, especially in 
those illegitimately pregnant and in those over thirty years 
of age. In multigravidse it is more commonly associated with 
multiple pregnancy, and with exposure to dampness and cold 
in women of the poorer classes who are underfed and over- 
worked. Women who are deficient in action of the skin, kid- 
neys, and bowels are good subjects for eclampsia should they 
become pregnant. 

Eclampsia— Symptoms. 

Premonitory symptoms usually manifest themselves some 
time before the eclamptic convulsion. These are : a condi- 
tion of irritability and heaviness ; frontal headache ; dis- 
ordered vision ; and diminished secretion of urine. Occa- 
sionally fedema of the face and limbs is present ; and not 
infrequently more or less severe epigastric pain. The general 
vascular tension is usually markedly increased. Rarely 
eclampsia occurs without any premonitory symptoms. 

The urine is diminished in quantity to from one-half to one- 
third the average in health. The specific gravity is very high, 
from 1030 to 1045 ; in rare cases it may be lower than nor- 
mal, 1010 ; and the quantity of urine undiminished. 



I 



ECLAMPSIA. 189 

Albumin is, as a rule, present in the urine in very large 
quantities, though it may in rare cases be absent. The albu- 
minous precipitate is composed of serum-albumin and para- 
globulin. The presence of large quantities of serum-albumin 
in the urine indicates very extensive damage to the renal cells, 
in which case the prognosis is rendered more serious. 

To distinguish the relative amounts of the two kinds of 
albumin, the urine must first be saturated with magnesium 
sulphate to precipitate the paraglobulin. After filtering, the 
filtrate may be tested for serum-albumin by the nitric-acid or 
heat test. The precipitate obtained from the filtrate may 
then be compared with that thrown down by heat or nitric 
acid in a specimen which has not been saturated wdth magne- 
sium sulphate, and the difference noted. 

Urea is, as a rule, largely diminished, not only in quantity, 
but also in percentage. 

Casts may or may not be found in the urine. 

Leucin and tyrosin, if sought for, will usually be found in 
the urine of eclamptics. 

The eclamptic fit usually begins with a fixed expression of 
the eyes, the head being turned to one side ; the eyelids twitch 
rapidly, the pupils contract, and the eyeballs roll. The spasm 
of the muscles then spreads rapidly, the mouth is drawn to 
one side, the jaws clench, often causing severe injury to the 
tongue, which may be caught between the teeth ; the head is 
rolled rapidly from side to side and then drawn back ; as the 
muscles of the trunk and limbs become affected the whole 
body is thrown into a condition of tonic spasm. As respira- 
tion is interfered with the face becomes livid and bloody froth 
issues from the mouth. 

This condition is rapidly succeeded by a series of clonic 
spasms in which all the muscles are thrown into violent con- 
tractions, causing quick jerking movements of the limbs and 
head. In severe cases the woman may be thrown into a posi- 
tion of opisthotonos. 

Consciousness is lost during the attack and the patient 
usually remains in a condition of coma, breathing stertorously, 
for some time after. 

The duration of the fit is seldom longer than a minute, 
while the coma lasts a variable time, from a few minutes to 



190 PATHOLOGY OF PREGNANCY. 

several hours. The paroxysms are repeated at varying inter- 
vals, in which the patient may regain consciousness. In some 
cases the patient remains in a condition of coma, with or with- 
out restlessness. Sometimes restlessness precedes another 
paroxysm. As many as 160 fits have been counted in one 
case. 

Course and Terminations. 

Eclampsia ends in recovery or death in from thirty-six to 
forty-eight hours. 

Death may occur from oedema of the brain, of the lungs or 
of the larynx, asphyxia, exhaustion, or heart-failure. An 
overwhelming accumulation of the toxins in the system may 
cause the coma to grow deeper and deeper, with or without 
the cessation of fits. Not infrequently the temperature 
steadily rises, and the patient dies with hyperpyrexia. 

Recovery takes place in about two-thirds of all cases under 
proper treatment. The fits cease, the secretion of the urine 
increases, and the coma fades gradually, though mental con- 
fusion often persists for some time. The bowels and skin 
become active. In some cases a condition of puerperal in- 
sanity may complicate the recovery ; but when it occurs it 
is generally mild and passes off in a few days. 



Etiology. 

While we do not know the cause of eclampsia, the present 
view most generally accepted is that it is the result of a 
toxaBmia, originating in the bodies of the mother and of the 
foetus. The urine of a healthy individual is highly charged 
with toxic materials. Bouchard has isolated from the urine 
two substances which produce convulsions, and one which 
produces coma. The urine of the albuminuric patient has 
been proved to be much less toxic than in the normal state ; 
while the urine of the eclamptic is scarcely toxic at all. 

In the eclamptic there is a diminution of the urinary 
secretion ; combined with this is an absence of toxicity of the 
urine and an arrest of elimination of the toxins. Coinciding 
with the disappearance of the toxicity of the urine there are an 
arrest of elimination of and an accumulation of toxins in the 



PATHOLOGICAL ANATOMY OF ECLAMPSLL 191 

blood. That the toxins are retained in the blood has been 
proved by an examination of the blood-serum of eclamptics. 
It has been found that in these cases the toxicity of the blood- 
serum is in inverse proportion to the toxicity of the urine. 

As to the formation of these toxins but little is known. It 
is supposed by some that they originate chiefly from the pres- 
ence of the foetus in the uterus ; but the most generally 
accepted view is that they originate from the decomposition 
of food within the bowel. The liver probably plays an im- 
portant part in the destruction of the toxins, while the kid- 
neys and skin are charged with their elimination. 

It is a well-known fact that the pregnant woman rarely ex- 
cretes a normal amount of urea. Urea is the most powerful 
diuretic known, and it is probable that its function is to 
stimulate the kidneys to the elimination of the toxins. 
Hence when the urea is diminished the kidneys are deprived 
of their stimulus to the excretion of these poisons. 

The effect of the efforts of the liver and the kidneys to 
break up and eliminate the toxins is to bring about certain 
changes in their structure which explain the presence of 
albumin, as well as of leucin and ty rosin, in the urine. 

Pathological Anatomy of Eclampsia. 

The kidneys : In most cases in which necropsies have permit- 
ted the examination of the kidneys, these organs presented 
macroscopic evidences of either acute or chronic nephritis. 
In some cases the kidneys have appeared perfectly healthy. 
But in all cases in which the kidneys have been microscopically 
examined, certain changes in the structure have been found 
which are not those of inflammation, but rather of degenera- 
tion, and very similar to those changes associated with blood- 
poisoning. 

This degeneration seems to be of a colloid nature, and is 
usually most marked in the epithelial cells of the tubules of 
the cortex. To the naked eye, kidneys whicli have under- 
gone this degeneration have very much the appearance of 
parenchymatous nephritis, and it is only h\ means of the 
microscope that the true character of the change present can 
be made out. 



192 PATHOLOGY OF PREGNANCY. 

Thus in eclampsia the lesion present in the kidneys is not 
nephritis, but an acute degeneration due to toxins in the blood. 

The liver : Hemorrhages into the substance of the liver are 
the most marked change to be noted in these cases. They 
occur as dark-red stains or blotches, and may be very ex- 
tensive ; or so slight as only to be revealed by the microscope. 
Between the sites of the hemorrhages the liver-cells show 
either fatty degeneration or actual necrosis. These changes 
can only result from severe contamination of the blood. 

The spleen presents, as a rule, very much the same changes 
as those found in the liver. 

The lungs and brain usually show certain changes, which 
probably result chiefly from the convulsions. 

Diagnosis. 

Eclampsia has to be distinguished from convulsions due to 
epilepsy, hysteria, and organic brain disease. The distinction 
may be made by an examination of the urine. 

Prognosis of Eclampsia. 

Maternal mortality is about 30 per cent., while the foetal 
mortality is about 50 per cent. The earlier in pregnancy the 
eclamptic condition occurs the worse is the prognosis. 

Prognosis is favorable- when : 

The attacks are infrequent and mild ; 

The patient regains consciousness between the attacks ; 

The skin, bowels, and kidneys can be stimulated to func- 
tionate freely. 

Prognosis is unfavorable when : 

The attacks become progressively more severe in spite of 
treatment ; 

The urine is completely suppressed, and purgation cannot 
be induced. 

Treatment. 

The prophylactic treatment of eclampsia consists in the 
frequent examination of the urine, with special regard to the 
quantity secreted, the percentage of urea and of albumin, 
and the presence and character of sediment. 



TREATMENT OF ECLAMPSIA. 193 

The bowels and shin should be kept active by the internal 
and external use of Avater, and mild laxatives should be 
employed regularly if required. 

The patient should be ordered a readily oxidized and non- 
constipating diet, and outdoor exercise in moderation, and 
directed to avoid exposure to cold and dampness. 

Medical treatment : Should the urea present in the urine 
fall to 1.5 per cent., then treatment should be inaugurated, as 
this indicates renal inadequacy. 

The nitrogenous diet should be reduced by placing the 
patient on a diet of milk, fish, and white meats. Elimination 
of the toxins by stimulating the action of the bowels, skin, 
and kidneys is the object of treatment. This object can be 
obtained by the regular use of a pill of aloes and colocynth, 
gr. V. at bedtime, warm baths two or three times a week, and 
the free use of drinking-water. The occasional employment 
of a dose consisting of calomel and soda, da gr. x, will be 
found to stimulate the action of the liver. 

When this treatment fails to improve matters, the patient 
should be put to bed, and the diet limited to milk as far as 
possible. The eliminative treatment already suggested may be 
reinforced by the daily lavage of the colon with at least two 
gallons of normal salt solution at a temperature of 100° F. 
The pill of aloes and colocynth may be replaced by Epsom 
or Rochelle salts in these more serious cases. 

The kidneys being already overtaxed, the employment of 
stimulating diuretics should be avoided. 

During the eclamptic attack the following scheme of treat- 
ment offers the best chance of success in the author's opinion : 
During the convulsion administer chloroform, and also when- 
ever for any reason the patient is to be disturbed, should it be 
found that such disturbance tends to precipitate a convulsion. 
Then inject hypodermically ext. veratr. viridis (tllxv) and 
give an enema containing chloral hydrate (3J in four ounces 
of water), and place two drops of croton oil on the back of the 
tongue. Have the patient's clothing entirely removed, and 
envelop her body in blankets wrung out of hot water, covering 
these with several dry ones. Then inject into the colon by 
means of a large-sized catheter attached to a fountain-syringe 
several quarts of warm saline solution. Where possible a 

13— Obst. 



194 PATHOLOGY OF PREGNANCY. 

pint or more of sterile saline solution should also be injected 
under the breasts, using a large exploratory needle for this 
purpose. 

Should the convulsions recur and the patient be a full- 
blooded, strong woman, a pint or more of blood may be 
drawn by opening one or more of the large veins of the arm. 
The veratrum, in TlXv doses, may be injected at short intervals 
till the pulse is reduced to 70 per minute. The chloral enema 
should be repeated every four hours, provided the condition 
of the pulse is satisfactory. As soon as the patient can swallow, 
dessertspoonful doses of a concentrated solution of Epsom 
salt may be administered every fifteen minutes till the bowels 
are acting freely. The hot packs should be renewed suf- 
ficiently often to keep up free diaphoresis. 

The obstetrical treatment : When should pregnancy be ter- 
minated in those cases in which eclampsia is threatened ? 
When, in spite of active treatment, the patient's condition 
gets steadily worse, or where improvement is only transient 
and relapses occur, the only safe course is to terminate the 
pregnancy. 

AYhea eclampsia occurs during parturition interference 
with the progress of labor should be avoided until the os 
is fairly well dilated. Accouchement force is to be con- 
demned, except in very rare instances. The convulsions must 
first be combated, and as a rule labor comes on spontaneously. 
It may be terminated by forceps in order to prevent its undue 
prolongation, as soon as the os is moderately dilated, the 
patient always being deeply anaesthetized for this purpose. 

The after-treatment consists in keeping up free action of 
the emunctories. Daily doses of Epsom salt should be given. 
The patient should be encouraged to drink large quantities of 
cream of tartar water, 3J to the pint. The diet should be 
limited to milk until the kidney condition has improved. 
Heart tonics may be required, and none is better than strych- 
nine in full doses. 

ABORTION AND PREMATURE LABOR. 

Definition : Abortion is the term used to denote the expul- 
sion of the ovum up to the end of the third month of preg- 



SY3IPT0MS OF ABOBTTON. 195 

nancy. Premature labor signifies the birth of a viable foetus ; 
"while the term miscarriage is usually applied to the expulsion 
of the ovum between the fourth and sixth months of preg- 
nancy. 

Frequency : It is impossible to estimate correctly the fre- 
quency of abortion ; but it is probable that the proportion of 
abortions is about one in every three or four pregnancies. 

Symptoms. 

The cardinal symptoms of abortion are, pain, hemor^rhage, 
and the expulsion of the ovum. The pain is due to uterine 
contractions ; and the hemorrhage results from the separation 
of the ovum from its uterine attachments. 

In some cases the hemorrhage is the first symptom, the pain 
following after the ovum has been converted into a foreign 
body by the blood having caused a separation of the mem- 
branes from the decidua. 

In other cases the pains precede the hemorrhage ; in this 
instance the abortion is more prolonged, as a result of the 
slow^ separation of the membranes. It is in this class of cases 
that preventive treatment is more likely to be successful. 

Abortion may take place suddenly ; or it may last over 
several days. 

Abortion occurring at or before the eighth week partakes 
of the character of a painful and rather profuse menstruation. 
Such it is often supposed to be by the patient. In some cases 
the uterine colic may be so severe as to cause vomiting or ner- 
vous chills ; the ovum usually passes unnoticed with blood- 
clots. On bimanual examination the uterus Avill be found 
enlarged and the os more or less patulous. When the abor- 
tion is not complete fragments of the ovum may be felt within 
the cervix. 

At the third month, which is the most common period for 
abortion, the process generally occurs in two stages : first, the 
expulsion of the foetus ; and second, the expulsion of the 
newly formed placenta and membranes. The process is more 
prolonged and more painful than in the earlier months. In 
some cases, especially when the foetus has been dead for some 
time, the placenta and membranes may soon follow its expul- 



196 PATHOLOGY OF PREGNANCY. 

sioii. Should the placenta remain adherent, the cervix may 
close again, though the pains and hemorrhage may continue. 
As the placenta is softer and more attached to the uterus than 
it is later, it is more apt to come away piecemeal ; hence por- 
tions may be retained for days, weeks, or even months, and 
give rise to a varied train of symptoms. 

Abortion after the fourth month gives rise to the clinical 
phenomena of a miniature labor. 

Pathology of Abortion. 

As the result of uterine contractions, or from degeneration 
of the vessels, blood is effused from the ruptured vessels into 
the decidua vera, and forces its way between the decidua and 
chorion, stripping oiF the ovum, which is then expelled entire. 
If the ovum be floated in water, it presents very much the 
appearance of a chestnut-burr. 

Occasionally the decidua is cast off entire along with the 
ovum, which it completely envelops. 

Occasionally also blood is extravasated into the membranes, 
at intervals. This coagulates in strata, and leads to the for- 
mation of what is known as a blood-mole. 

In some cases the abortion may not be completed for some 
time, and the coloring-matter of the eifused blood may be 
absorbed, while the strata undergo partial organization and a 
fleshy mole results. This may form a connection with the 
uterine wall, and be retained indefinitely^ 

In those cases in which portions of placenta are retained 
these masses may form polypi, remaining in the uterus for 
weeks or months, causing a fetid discharge and an elevation 
of temperature. 

Etiology. 

The causes of abortion may be divided into those of paternal, 
of maternal, or of fcetal origin. 

Paternal : Syphilis is probably the most common paternal 
influence in causing abortion. Other causes which may be 
mentioned under this heading are alcoholism, debility, tuber- 
culosis, lead-poisoning, advanced age, and excessive venery. 

Maternal: General: Similar causes to those mentioned in 
the father act in the mother. 



DIAGNOSIS OF ABORTION. 197 

Acute and chronic diseases cause abortion by excess of tem- 
perature, or by blood-changes, or by producing alterations in 
the placenta. Traumatism and severe emotional disturbances 
may produce abortion. Certain drugs, as quinine, savin, ergot, 
and a host of others, are said to cause abortion ; but it is 
doubtful if this is the case when the uterus is in a normal 
condition. 

Local : Displacements of the uterus, pelvic inflammations 
or adhesions, cervical lacerations, endometritis, metritis, fibro- 
myomata, and abnormal development of the uterus may be 
mentioned as conditions which predispose to abortion. 

There are women who abort constantly in whom no reason- 
able cause can be found ; to this condition the term " habitual 
abortion '^ is applied. 

Fcetal : Sypliilis, which acts by producing changes in the 
ovum or in the placenta, leading to the death of the foetus, is 
probably the most common foetal cause of abortion. 

Degeneration of the chorion, hydramnios, and vicious inser- 
tion of the placenta frequently result in abortion. 

Diagnosis. 

In cases of suspected abortion it is necessary to determine 
the existence of pregnancy. The abortion may be threatened; 
inevitable ; or wholly, or partially accomplished. 

Threatened abortion : If the patient has been exposed to 
the possibility of impregnation and the menses have been sup- 
pressed ; if a hemorrhage from the uterus occur, associated 
Avith more or less pain ; then it is probable that an abortion is 
threatened. 

Dysmenorrhoea may be mistaken for impending abortion ; 
but in this case the .cervix is closed and firm to the feel. 
Hemorrhage, associated with the presence of a soft polypoid 
tumor in the uterus, may simulate the condition of threat- 
ened abortion very closely ; but a careful local examination 
will generally establish the nature of the condition present. 

Inevitable abortion : AYhen the membranes have ruptured, or 
the foetus is dead, or when any foetal part is engaged in the cer- 
vix, the abortion may be said to be inevitable. Cases have 
occurred in which large portions of decidua have escaped from 



198 PATHOLOGY OF PREGNANCY. 

the uterus, associated with considerable hemorrhage, and yet 
have afterward gone on to full term. Again the os may 
open sufficiently to admit the finger, yet close again, and the 
pregnancy continue. It is, therefore, sometimes a difficult 
matter to say that an abortion is '^ inevitable.'^ 

Complete, or partial, abortion : It is important always to de- 
termine whether a part of, or the whole uterine contents have 
been expelled. To make a diagnosis, everything discharged 
from the uterus must be carefully examined ; when any doubt 
remains a digital exploration of the uterine cavity must be 
made ; when anything is retained, the cervix usually remains 
patulous so that the finger can be inserted without much dif- 
ficulty. 

In cases of complete abortion in the first two months of 
pregnancy there is functionally no lochial discharge. Should 
the hemorrhage continue it is probable that portions of the 
decidua have been retained. 

In incomplete abortions at the third month, or later, the 
lochial discharge remains free and bloody, instead of gradually 
subsiding, as it should when the uterus has been emptied and 
is involuting properly. 



Prognosis. 

The prognosis of abortion depends upon the treatment. 

If the uterus has been carefully emptied under aseptic pre- 
cautions, then the mortality from abortion should be nil. 

Retained masses of decidua or of placenta are followed by 
decomposition of these substances in utero, and acute or 
chronic septic infection is the result. 

Hemorrhage very rarely leads to a fatal result in cases of 
abortion. 

When neglected, abortion may be the starting-point of vari- 
ous uterine diseases, as subinvolution, metritis, etc., which 
may lead to invalidism. 

Treatment of Abortion. 

Prophylactic : When any of the conditions are present which 
may tend to premature expulsion of the ovum, all precautions 



TREATMENT OF ABORTION. 199 

must be taken to prevent such an accident. Appropriate 
systemic treatment should be undertaken when indicated, and 
at the same time the patient should be instructed to observe 
special precautions, such as the avoidance of overexertion 
by lifting or reaching, particularly at the menstrual periods. 
I'he use of strong purgatives should be avoided. At each 
menstrual epoch the patient should remain in bed for several 
days. Abnormal uterine conditions, such as displacements, 
metritis, and lacerations of cervix, should receive appropriate 
treatment. Sexual intercourse should be avoided, especially 
at or about the menstrual epochs. 

Threatened abortion : The main principle of treatment is to 
secure for the patient absolute rest, mental and physical. 
This is obtained by putting her to bed, in a cool, darkened 
room, where she can be kept in absolute quietness ; and by 
the free use of opium, bromide, and chloral. 

Opium is best administered by the rectum. A suppository 
containing opium, gr. ss, should be gently inserted every eight 
hours, or at least sufficiently often to keep the patient well 
under the influence of the drug. At the same time a m.ixture 
containing sodium bromide, gr. xxx, and chloral hydrate, gr. 
XV, may be given three times daily. Many prefer the fluid 
extract of viburnum prunifolium in drachm doses, t. i. d., 
instead of the bromide and chloral mixture. 

Inevitable abortion : Two methods of treatment are avail- 
able, the expectant and the active : 

The expectant treatment : Should the bleeding be severe 
before the os is dilated, it must be controlled by means of a 
vaginal tampon of sterile or iodoform gauze. To apply va- 
ginal tamponage properly the patient should be placed in the 
left semiprone position, with the hips resting on a rubber 
sheet or Kelly pad at the edge of the bed. The vulva and 
vagina should then be washed Avith spirits of green soap and 
hot water, and then swabbed with a 1 : 500 formalin solution. 
If the vulvar hair is long, it should be clipped. The only 
instruments required are a Sims speculum, a pair of uterine 
forceps, and a pair of scissors, which may be sterilized while 
the patient is being prepared. 

The speculum is then inserted and the perineum retracted 
so as to expose the cervix to view. A strip of gauze (sterile 



200 PATHOLOGY OF PREGNANCY, 

or iodoform), about two inches wide and a yard long, is then 
seized above by means of the uterine forceps and packed 
firmly around the cervix. As the gauze is being inserted the 
specuhim is gradually withdrawn. A sufficient quantity of 
gauze should be introduced to distend the vagina. The 
patient is then made comfortable, and should remain in bed. 

To facilitate the emptying of the uterus, the fluid extract of 
ergot may be administered in half-drachm doses three times 
daily. If the uterine contractions are painful, an opiate may 
be combined with the ergot. The vaginal tampon should be 
removed in twenty-four hours, and replaced by a fresh one if 
necessary. A close watch should be kept over the patient's 
temperature. Often when the first tampon is removed the 
ovum comes with it, or the cervix will be found softened and 
the OS sufficiently dilated to permit the introduction of the 
finger, with which the ovum may be extracted. If the ovum 
rupture and a part be retained in the uterus, the woman 
must be kept in bed, the ergot continued, and the vagina 
daily douched with a solution of formalin, 1 : 500. In many 
cases this treatment will be sufficient ; but in spite of every 
precaution the discharges may become foul and the tenipera- 
ture rise, in which case the uterine cavity must be thoroughly 
curetted. 

Active treatment : This is the treatment to be recommended, 
in preference to the expectant plan, in the large proportion of 
cases. The vaginal tampon may be employed, as recommended 
above. If at the end of twenty-four hours the os is not 
patulous, the patient should be anaesthetized, and the cervix 
dilated with Hegar's or Barnes's dilators, and the uterus 
emptied, as recommended below. 

As soon as the os is sufficiently dilated to permit the intro- 
duction of the forefinger the ovum should be sW^ept out and 
the decidua or placenta removed by scraping. The forefinger 
of the right hand is the best instrument for tl s purpose. It 
can be made to reach all parts of the uterus, with the assist- 
ance of the left hand pressing on the fundus through the 
abdominal wall. When the secundines cannot all be removed 
in this manner the interior of the uterus may be gently 
scraped with a blunt curette. In all cases, after emptying the 
uterus its cavity should be thoroughly douched with plain 



MISSED LABOR. 201 

sterilized water or formalin solution, used hot. For this pur- 
pose the Fritsch-Bozeman uterine catheter is by far the best 
instrument. The Emmet curette forceps will be found to be 
a very valuable adjuvant to the curette in removing shreds 
from the uterine cavity. 

After-treatment of abortion: The woman should be kept in 
bed for at least a week or ten days, the temperature should be 
watched, and, if necessary, appropriate treatment to prevent 
the onset of lactation should be applied. 

Missed Abortion. 

It occasionally happens that the foetus perishes, symptoms 
of impending abortion develop only to disappear, and the 
ovum is retained in the uterus for weeks, or even months. To 
this condition the term ^^ missed abortion '' is applied. No 
treatment is indicated, provided the condition does not affect 
the general health of the patient, for sooner or later contrac- 
tions will occur and the uterus empty itself of its contents. 

Premature Labor and Miscarriage. 

The phenomena of premature labor are very much the 
same as of labor at term, with the exception that the placenta 
is more frequently adherent to the uterine wall. When such 
is the case the uterus must be entered and the placenta 
stripped off and removed, after which a hot uterine douche 
should be given. 

Missed Labor. 

In this condition, which is very rare, the woman may 
exhibit a few ineffectual signs of labor at term ; these disap- 
pear, and the product of conception is retained in utero for 
months, or even years. The foetus in these cases always 
perishes, and either macerates or mummifies. The soft parts 
of the foetus may be absorbed, and the bones may be dis- 
charged at intervals for a long time afterward, or they may 
find their way through the uterus into the bladder or rectum. 
It is a good general rule to induce labor in all cases in which 
the patient is known to have gone two weeks beyond the nor- 
mal period of pregnancy. 



202 PATHOLOGY OF PREGNANCY. 



ECTOPIC GESTATION. 

Definition : When the impregnated ovum becomes attached, 
and develops outside the uterine cavity, the pregnancy is 
termed ectopic, or extra-uterine. 

Frequency : Ectopic gestation occurs probably about once 
in 500 cases of pregnancy. 

Varieties : There are three primary forms of ectopic gesta- 
tion: (1) tubal ; (2) ovarian; and (3) abdominal. 

Many authorities classify the various terminations of these 
primary forms of ectopic gestation as secondary forms, each 
being designated according to the location of the displaced 
ovum. The term "secondary'' as thus employed simply 
means subsequent to rupture or displacement. 

While primary ovarian and abdominal pregnancies do 
occur, they are undoubtedly extremely rare, and are difficult 
of absolute demonstration ; as a general rule, ectopic gestations 
are tubal. 

Tubal pregnancies are classified according to the site of the 
attachment of the ovum, as : 

(1) Interstitial when the ovum develops in that portion of 
the tube which passes through the wall of the uterus, or in a 
diverticulum of this portion of the tube. 

(2) True tubal, or ampullar, when the ovum develops in 
the free portion of the tube. 

(3) Infundibidar when the ovum develops in the infundib- 
ulum of the tube, and prevents the closure of the abdominal 
ostium. Cases of this variety are also termed tubo-ovarian. 

Terminations of Ectopic Gestation. 

Interstitial pregnancies usually terminate about the third 
month by rupture into the peritoneal sac. The patient gen- 
erally succumbs to hemorrhage and shock. Rupture into the 
uterine cavity, with expulsion of the foetus through the cervix, 
is possible, as is also rupture into the base of the broad liga- 
ments. 

True tubal pregnancies terminate by rupture either (a) up- 
ward into the abdominal cavity, or (b) downward between 
the layers of the broad ligament. When the rupture occurs 



TERMINATIONS OF ECTOPIC GESTATION. 203 

into the abdominal cavity the hemorrhage is usually severe, 
and may be fatal in from sixteen hours to three or four days. 
When rupture occurs early and the hemorrhage is not severe, 
the foetus may be absorbed, as the embryonic sac usually 
ruptures at the same time as the tube. 

When the rupture occurs downward, between the layers of 
the broad ligament, the ovum may perish and all trace of it 
disappear, while the blood effused may be retained, forming a 
pelvic hsematocele. The ovum may develop for a time, and 
then burst into the peritoneal cavity, or continue to full term 
by stripping the peritoneum from the pelvic wall as it en- 
larges. In either case the ovum develops for a time and 
then perishes, and is either absorbed or macerated, when it 
may ulcerate through into the bowel, bladder, or vagina, and 
escape. 

In still other cases the gestation-sac may undergo putrefac- 
tion from access of bacteria from the bowel, and be converted 
into a broad-ligament abscess, which may rupture into the 
peritoneal cavity, or into the bladder, rectum, or vagina. In 
other cases the foetus after death may be converted into a 
lithopaedion or may be mummified, and thus remain for 
years. 

Infundibular pregnancies may either rupture into the perito- 
neal cavity or develop to full term. 

Ovarian pregnancies may terminate by rupture of the sac 
and profuse hemorrhage ; or arrest of development may 
occur at an early period and the sac remain a cystic tumor. 
Advance to full term is possible, but not probable. 

Abdominal pregnancies may advance to full term ; or the 
sac may rupture early, and the foetus be either absorbed or 
mummify. 

Tubal abortion : This term is applied to a certain rare con- 
dition in which blood is effused into the ovum, destroying it 
and its attachments to the tube-walls. The ovum may re- 
main as a tubal mole, forming a solid tumor of the tube ; or it 
may escape with the blood from the fimbriated extremity of 
the tube into the abdominal cavity. 



204 PATHOLOGY OF PREGNANCY. 

Etiology of Ectopic Gestation. 

As has been stated, the ovum usually becomes 'impreg- 
nated while still in the Fallopian tube. If the tube is in 
a normal condition, the impregnated ovum is moved along 
it until it finds its resting-place in the uterine cavity. It is 
therefore probable that the most important factor in producing 
ectopic gestation is some abnormal condition of the tubes. 

Such abnormal conditions may arise either from inflam- 
mation of the tissues of the tubes or from parametritic 
exudations, which lead to their constriction or destruction. 
Malformations of the tubes are not infrequent, such as di- 
verticula, accessory tubal canals, etc., and have been noticed 
in connection with ectopic gestation. 

Any diseased condition of the mucous membrane of the 
tubes, or any condition which interferes with their normal 
peristaltic action, may be said to favor the development of 
ectopic gestation. 

The condition is generally encountered in women who 
present a history of a protracted period of sterility. 

Pathology of Ectopic Gestation. 

The uterus : With the establishment of pregnancy the 
uterus begins to enlarge ; the enlargement continues through- 
out the pregnancy, though at a much slower rate than is the 
case in intra-uterine gestation. As a rule, this organ begins 
to involute when the foetus perishes. A decidua forms in 
all cases of ectopic gestation, which is quite similar to the 
decidua vera of normal pregnancy. It is cast off either 
complete or in shreds, at the time of the primary tubal 
rupture, whether the ovum perishes or not. The shredding 
of the decidua is invariably accompanied with metrorrhagia. 
The decidua varies in thickness from one-eighth to one-fourth 
of an inch ; it is shaggy on its uterine side, while its inner 
surface is quite smooth and shows no trace of either the 
decidua serotina or reflexa. 

Changes in the tube and ovum : As the tube enlarges its 
relation to surrounding parts becomes greatly modified. The 
first change in the tube is a turgescence, due to increase in 
size of the vessels, the result of the stimulus of pregnancy. 



SYMPTOMS OF ECTOPIC GESTATION. 205 

The muscle-fibres of the tube's walls then increase in size, 
but later atrophy as the result of minute ruptures due to small 
hemorrhages into their substance. Then folloAvs free develop- 
ment of connective tissue, which replaces in great part the 
muscle-fibres. As the ovum enlarges the tube-walls become 
thinned out, the thickest part being at the site of the placental 
attachment, and the thinnest directly opposite. Closure of 
the abdominal ostium usually takes place at the sixth or 
seventh week ; rupture of the tube takes place before the end 
of the second month in probably two-thirds of the cases. 

The tube is movable to a limited degree until fixed by peri- 
tonitis. From its increased weight it tends to fall below its 
normal level, and it may be found in Douglas's pouch. As the 
ovum enlarges the uterus is pushed to one side. In some 
cases the tube remains closely attached to the uterus, while in 
others it forms a distinct mass. 

In the pregnant tube a decidua is formed Avhich is composed 
of the usual two layers, a superficial compact and a spongy 
lower layer. That portion of the decidua which is to form 
the maternal placenta, and which corresponds to the serotina, 
grows more rapidly than that in the rest of the tube. A de- 
cidua reflexa is also formed, but it tends to degenerate rapidly, 
and gives rise to hemorrhages very early in the pregnancy. 
These hemorrhages result in inflammatory changes which alter 
the general texture of the mass. 

The placenta is formed in the same way as in intra-uterine 
gestation, but the lack of space in the tube results in trauma- 
tisms which altogether change its character, converting it into 
a liver-like mass. When the tube ruj^tures the torn walls 
of the tube spread out, and should the ovum survive, the pla- 
centa forms attachments to neighboring structures and con- 
tinues its growth. 

The amnion and chorion are only altered from their usual 
conditions by the results of trauma and sepsis. 

Symptoms of Ectopic Gestation. 

The phenomena which indicate the existence of ectopic ges- 
tation are : irregular hemorrhages from the vagina accompanied 
with more or less severe pelvic pain; and the presence of a mass 
close to and often associated with the iderus. 



206 PATHOLOQY OF PREGNANCY. 

In a typical case the patient has been regular in menstrua- 
tion for some time, when she misses a period. Shortly after 
this she has irregular attacks of bleeding, accom})anied with 
sharp, cutting pelvic pain. These symptoms may lead to the 
suspicion of abortion, which is strengthened by the passage 
of portions of decidua. One of these attacks may be exces- 
sively severe and cause collapse. Not infrequently these 
attacks are accompanied by dysuria and rectal tenesmus. 

The amount of blood lost varies from a mere show to a 
severe hemorrhage ; with the blood may be found small shreds 
of mucosa, or even a complete cast of the decidual lining of 
the uterus. 

The pelvic pain is usually of a sharp, tearing character ; 
when excruciating, and accompanied with collapse, it indicates 
a serious rupture. 

A vaginal examination in such a case will reveal the pres- 
ence of a mass in close proximity to the uterus, which may 
be found somewhat enlarged. The character of the mass de- 
pends upon the situation of the ovum and whether it has rupt- 
ured or not. In cases in which rupture has taken place early 
into the general peritoneal cavity no mass may be felt. 

If the first attack be survived, other similar attacks may 
follow and the internal hemorrhages be fatal. In other cases 
the effused blood may be absorbed after the perishing of the 
ovum. 

The ovum if it survive may go on developing, in which case 
signs of pregnancy will continue, an abdominal tumor develop, 
and finally evidences of a living foetus will manifest them- 
selves. Such cases may go on to full term and a spurious 
labor occur. 

In other cases secondary rupture takes place at a later period 
when the patient usually dies of hemorrhage or peritonitis ; or 
if the patient survive, the foetus becomes mummified or forms 
a lithopsedion, being retained for some time, and finally is cast 
out piecemeal through a fistulous opening. 

Diagnosis. 

To make a positive diagnosis of ectopic gestation previous 
to rupture of the sac, while possible in a large majority of 



TREATMENT OF ECTOPIC GESTATION. 207 

cases, is always a matter of difficulty. The liistory of the 
signs of early pregnancy, associated with aggravated reflex 
nervous phenomena ; the early appearance of sharp, cramp- 
like pelvic pain increasing in severity, make a diagnosis pos- 
sible. 

Usually the condition is not recognized until rupture has 
taken place. At this time the history of delayed menstrua- 
tion, the occurrence of a paroxysm of frightful pain, sudden 
collapse, and symptoms of internal hemorrhage make the 
diagnosis very simple. 

A microscopical examination of the shreds contained in the 
vaginal blood will reveal their decidual character, and make a 
differential diagnosis from abortion possible, as no chorionic 
villi will be found unless the pregnancy is intra-uterine. 

In cases of advanced ectopic gestation the diagnosis is, as a 
rule, not difficult. Owing to the great displacement of con- 
tiguous organs, abdominal pain is often excessive. This pain 
is due in part to pressure, and in part to the development of 
peritonitis of a chronic type. 

Prognosis. 

Ectopic gestation is one of the most serious obstetrical condi- 
tions. If left to nature, the mortality is over 60 per cent., the 
remainder recovering by death of the ovum and absorption 
of the contents of the gestation-sac. 

When treated by abdominal section. Hirst states the mor- 
tality should be about 5 per cent, or lower, if the operator 
sees the patient in time. 

Treatment. 

As soon as a diagnosis of ectopic gestation is established 
the only rational treatment consists in the immediate removal 
of the gestation-sac, whether it has ruptured or not. 

Abdominal section is the most satisfactory metliod of operat- 
ing, though some operators prefer the vaginal route. The 
latter method has many disadvantages, and should only be 
resorted to by those operators having special experience in 
operating by the vaginal route. 

As it is a matter of considerable difficulty in many cases to 



208 PATHOLOGY OF PREGNANCY. 

control the hemorrhage and to separate the gestation-sac, the 
operation of (ibdominal section for the removal of an ectopic 
gestation should not be undertaken by an unskilled operator. 

The technique of the operation : Though the operation has 
frequently to be performed in an emergency, plenty of time 
should be taken to secure an aseptic condition of the abdomen 
of the i)atient, of the operator, of the assistants, and of the 
instruments and dressings. 

The operator, having opened the abdomen by a median 
incision, should at once insert his hand and seize the affected 
tube at its uterine end, so as to control the hemorrhage. The 
broad ligament should then be transfixed by a pedicle-needle 
to the inner side of the round ligament, and the tube ligated 
eii masse. After the tube and ovary have been cut away, the 
abdominal cavity should be cleared of clots, if necessary flush- 
ing it with a large quantity of warm sterile water. The 
incision may then be closed without the insertion of a drain- 
age-tube, unless a considerable number of adhesions have been 
encountered. The subsequent treatment is the same as for an 
uncomplicated ovariotomy. 

When the hemorrhage has been very considerable a quan- 
tity of sterile salt solution should be injected under each 
breast, during the operation, by an assistant. After the oper- 
ation it is advisable in all cases to inject at least a quart of 
the same solution into the bowel, by means of a long rubber 
tube and gravity syringe. 

In advanced ectopic pregnancy many advise that interference 
be delayed until just short of term. In this case effort should 
be made to enucleate the foetal sac whole. 

When this is found to be impossible, after the foetus has 
been removed the cord should be cut as close as possible to 
the placenta and the edges of the sac stitched to the edge of 
the abdominal wall, and the sac drained by packing it lightly 
with iodoform gauze. 

The after-treatment in such cases consists in daily irrigation 
of the sac with antiseptic solutions, dusting it well with an 
antiseptic powder, and introducing fresh packing. 

For further information on this subject reference should be 
had to standard gynaecological works, as ectopic gestation has 



DIAGNOSIS OF OCCIPITO POSTERIOR CASES 209 

passed from the domain of obstetrics to that of gynaecology, 
since the treatment of the condition is purely surgical. 

PATHOLOGY OF LABOR. 

The term eutocia is applied to normal labor which termi- 
nates easily Avithout serious damage to mother or foetus and 
without artificial aid. 

Dystocia is the term applied to abnormal labor. If the 
abnormality of the labor depends upon some form of foetal 
irregularity, the condition is termed foetal dystocia ; while if it 
be dependent upon some abnormal condition in the mother it 
is known as maternal dystocia. 

The cause of the dystocia may be in any of the three factors 
which constitute the mechanical problem of labor. The foetus 
or its appendages may be abnormal in size, shape, or position ; 
the expelling forces may be insufficient or excessive ; or the 
resistance offered by the maternal passages may be too great 
or too little. 

AYhen called upon to render assistance in a case of dystocia 
the physician should first ascertain which of the factors is at 
fault. The recognition of the disturbing cause forms the basis 
of rational treatment. 

DYSTOCIA DUE TO MALPOSITIONS OF THE FCETUS. 

OCCIPITOPOSTERIOR CASES. 

Occipitoposterior positions of the head are primary or 
acquired. 

Primary, if the head enters the brim of the pelvis with the 
occiput posterior. 

Acquired, if the occiput rotates from an anterior position at 
the beginning of labor to a posterior at its close ; the latter is 
very rare. 

Diagnosis of Occipitoposterior Cases. 

Abdominal examination : The back of the foetus may be 
felt in the maternal flank ; but is frequently difficult to out- 
line. The foetal members may be felt over the whole anterior 
aspect of the abdomen. The head can be felt at the pelvic 

14— Obst. 



210 



PATHOLOGY OF LABOR. 



brim, wliile the anterior shoulder can easily be distinguished 
at a point about midway between the middle of Poupart's 
ligament and the umbilicus. The foetal heart-sounds may be 
heard in the flank at about the level of the umbilicus. 

Vaginal examination : If the cervix is dilated sufficiently, 
the sagittal suture may be felt in the line of the oblique 
diameter of the pelvis, while the posterior fontanelle is 
directed toward the right or left sacro-iliac joint. Labor in 
occipitoposterior j)ositions is generally tedious, due to the 
irregular and ineffectual pains which characterize the first 
stage in these cases, and also because of the long internal rota- 
tion which must take place before the occiput is directed 
under the pubic arch. 



Mechanism of Occipitoposterior Cases. 

In normal cases the mechanism is much the same as in 
anterior positions of the occiput. Flexion is more difficult 
on account of the maladaptation of the head to the pelvis in 
these posterior positions, as the widest part of the head, the 
biparietal, is in relation with the narrowest part of the inlet, 
the diameter between the iliopectineal prominence and the 



Fig. 67. 



Fig. 68. 





Right occipitoposterior position of 
head. The arrow shows the direction of 
the long internal rotation made by the 
occiput in delivery. (.Jewett.) 



Left occipitoposterior position of head. 
The arrow shows the direction of the long 
internal rotation made by the occiput in 
delivery. (Jewett.) 



promontory. AVhen flexion is complete and the head de- 
scends to the pelvic floor, internal rotation is prolonged on 
account of the great distance the occiput must traverse to 
come under the pubes ; hence there is greater pain, and the 
labor is prolonged (Figs. 67 and 68). 



MECHANISM OF OCCIPITOPOSTERIOR CASES. 211 

Abnormal Mechanism. 

(1) Extended position of head : The disproportion between 
the occipital end of the head and that portion of the brim in 
relation to it already referred to, may result in interference 
with flexion to such an extent that the head may enter the 
pelvis in an extended position^ as in brow or face presenta- 
tions. 

(2) Face to pubes : When the head enters the pelvis imper- 
fectly flexed the sinciput may reach the pelvic floor first, and 
is then directed toward the pubic arch, while the occiput 

Fig. 69. 




Faulty mechauism in a right occipltoposterior case. The occiput is shown rotating 
to the back. (After Schultze.) 



rotates into the hollow of the sacrum. This mechanism 
results in delivery " face to pubes.'' 

In such persistent occipitoposterior cases the head con- 
tinues to descend until the glabella (the root of the nose) 



212 



PATHOLOGY OF LABOR. 



pivots under the piibes, when flexion takes place to permit the 
escape of the occiput over the perineum. When the occiput is 
delivered the head extends and the face escapes from under the 
pubes (Fig. 69). Spontaneous delivery in a face to pubes case is 
only accomplished with difficulty, and requires strong pains, 
lax maternal parts, and not too large a head. After the birth 
of the head the mechanism is the same as in other cases. 

(3) In other cases the head may enter the pelvis poorly 
flexed, descend until it reaches the pelvic floor, and there 
remain fixed with its long diameter (O. F.) transverse in the 
pelvic cavity, generally at the level of the ischial spines, 
between which it becomes impacted. 

Moulding of head in face to pubes cases : The occipito- 
mental and occipitofrontal diameters of the foetal head are 
shortened and the suboccipitobregmatic lengthened, as a 
result of the head pivoting at the glabella (Fig. 70). 



Management of Labor in Occipitoposterior Cases. 

Prophylaxis : Attention has been drawn to the desirability 
of making an abdominal examination to determine the posi- 
tion of the foetus some time before 
^^^' 70. the expected onset of labor. If at 

this examination the foetus be found 
to occupy a posterior position, it is 
possible to rectify it by postural treat- 
ment in many cases. The woman 
should be instructed to assume the 
knee-chest position as frequently as 
j)0ssible, and to remain in this position 
for some time before turning upon 
the side to which it is desired to 
direct the occiput. In this posture 
the tendency is for the child to sag 
away from the brim under the influ- 
ence of gravity, as the fundus and 
anterior uterine wall become the 
lowest portions of the uterus. The 
child thus becomes free to rotate upon its own axis, and as 
its dorsum is heavier from the presence of the spinal column 




Diafjram showing head un 
moulded and mouldedinaper 
sistent occipitoposterior case, 

Black, unmoulded. 

Red, moulded. 



LABOR IN OCCIPITOPOSTERIOB CASES. 213 

it is brought into apposition with the anterior wall of the 
uterus. Hence as the woman assumes the erect position 
the child's head tends to settle down against the brim in 
an anterior position. 

At the Pelvic Inlet. 

Frequent examinations should be made to ascertain whether 
flexion is being maintained as the head descends into the brim. 
Should extension of the head take place without descent, 
interference is demanded, as there is but little likelihood that 
the head will pass the brim by natural efforts. 

Three methods of delivery are possible : 

1st. Version : This is probably the most popular as well as 
the easiest method of dealing with these cases, because, as a 
rule, the general practitioner can perform this operation with 
greater ease to himself and less danger to the patient than 
either of the other methods. 

2d. Normal restoration of flexion and rotation of the foetal 
head and body to an anterior position, with the subsequent ap- 
plication of the forceps : This is a rather difficult operation, and 
should only be undertaken by those who are thoroughly 
skilful in the use of forceps. To perform this operation 
properly the patient should be placed under the influence of 
chloroform, so as to relax thoroughly the uterus. The opera- 
tor, after the usual antiseptic precautions have been observed, 
should then pass his whole hand into the uterus so as firmly to 
grasp the brow and face of the child. The head having been 
raised slightly, so as to free it from the brim, is then gently 
rotated to an anterior position. The external hand of the 
operator should be used to promote rotation of the trunk, 
which should accompany rotation of the head. The rotation 
should be carried out slowiy and with the utmost gentleness. 
After this has been accomplished the head should be urged 
into the brim by external pressure, and should be maintained 
in position by an assistant while forceps application is made. 
As in all high operations, only the axis-traction forceps should 
be used. 

3d. Application of the forceps without alteration of position : 
This operation should only be undertaken as a last resort, as 



214 PATHOLOGY OF LABOR. 

it is very dangerous both to mother and child. As a pre- 
liminary to this operation the head should be flexed. 



In the Pelvic Cavity. 

As in all posterior positions the head tends to pass the brim 
in a somewhat extended position, it is important to secure a 
speedy restoration of flexion, in order that the labor may be 
accomplished as easily and rapidly as possible, and to spare 
the patient unnecessary suffering. 

Flexion may be restored by pressure upward upon the 
sinciput with two fingers during the intervals between the 
pains. During the pains the descent of the sinciput may be 
retarded by maintaining this pressure from below. Occasion- 
ally it is possible to hook the finger of the other hand over 
the occiput and draw it down, while at the same time the 
sinciput is being pressed up ; but to do this the head must be 
very low and the parts lax. 

When rotation fails and signs of exhaustion occur, then the 
forceps must be applied. During this operation care should 
be taken to prevtmt the blades slipping, as this accident is very 
liable to occur. Between the tractions the blades should be 
separated, because sometimes the occiput tends to rotate spon- 
taneously. As the head emerges it should flex and the root of 
the nose pivot under the pelvic arch. It should be delivered 
slowly and with extreme caution, so as to favor moulding and 
to control the extent of perineal laceration. In many cases 
it is necessary to perform episiotomy, in order to prevent the 
laceration of the perineum extending into the rectum. 



Prognosis. 

The prognosis for both mother and child is not so favorable 
as in anterior positions. Backward rotation of the occiput 
takes place in about IJ per cent, of all cases of labor. 

Laceration of the maternal soft parts is frequent and often 
extensive. The mortality of the foetus is somewhat over 
9 per cent., as compared with 5 per cent, in anterior posi- 
tions. 



DIAGNOSIS OF FACE PRESENTATIONS. 215 



FACE PRESENTATIONS. 

Occurrence : Face presentations rarely exist prior to the 
onset of labor ; they may be considered as altered vertex pres- 
entations. Presentation of tlie face cannot be said to be com- 
mon, for it occurs once in about every 250 cases of labor. 

Positions : The chin is the denominator, as it replaces the 
occiput in the mechanism when compared to vertex presenta- 
tions, for the head is extended instead of being flexed. 

The long diameter of the face, the frontomental, usually 
occupies the right oblique diameter of the pelvic brim ; hence 
the most common positions are : R. M. P. and L. M. A.; 
rarely, R,. M. A. and L. INI. P. positions may be met with. 

Causes : Any condition wliich tends to interfere with proper 
flexion of the head may be set down as a cause of face pres- 
entation. The most common causes are : 

1. Obliquity of the uterus, which acts by altering the line 
of foetal-axis pressure. 

2. Tumors of the foetal neck, thyroid, or thymus. 

3. Coils of thick cord around the neck. 

4. Dead foetus. 

5. Excessive liquor amnii. 

6. Small size of foetus. 

7. Deformed pelvis. 

8. Tumors of uterus or neighboring structures. 

9. Tumors upon the back, as meningocele. 

10. Dolichoceplialic head. 

11. Occipitoposterior positions, in which there is a tight fit 
at the brim. 

Diagnosis of Face Presentations. 

Abdominal examination : It is sometimes a matter of diiB- 
culty to make a diagnosis of face presentation when the 
abdominal Avail is thick or tense. Usually the bulky cranial 
vault can be felt in one hypogastric region, and a deep groove 
may be made out between it and the foetal back. On the 
opposite side of the abdomen the foetal members may be dis- 
tinguished (Fig. 71). As the foetal back is displaced from 
the uterine wall by the extended head, the heart-sounds are to 



216 



PATHOLOGY OF LABOR. 



be heard most distinctly on the same side of the abdomen 
upon which the foetal extremities are felt. 

Vaginal examination : Early in labor before rupture of 
the membranes, the rounded head to be felt in the vertex 



Fig. 71. 




Transverse position of face at superior strait. 

cases is wanting, and usually nothing can be reached but the 
bulky bag of waters, as the face is arrested high up, Care 
should be taken not to rupture the membranes in attempting 
to reach the presenting part of the foetus. Should the bag of 
waters be ruptured, then it may be possible to distinguish the 



I 



MECHANISM OF FACE PRESENTATIONS. 217 

superciliary riclges, the eyes, the nose, and especially the mouth. 
The latter is distinguished by feeling the tongue and the 
alveolar margins. If the caput succedaneum has formed over 
the face, it may be mistaken for a breech, unless care be taken 
to distinguish clearly the relationship of the parts within 
reach of the finger. 

Mechanism of Face Presentations. 

The first stage of labor is delayed because the head does 
not fit the lower uterine segment so well as in vertex presen- 
tations. 

The mechanism of face cases differs from that of the 
vertex in that : 

1. The chin takes the place of the occiput in being the 
leading part of the head in descent. It does not come down 
so far in advance of the rest of the head as the occiput in 
vertex cases, so that internal rotation of the chin forward to 
the pubic arch occurs rather late and is slow. 

2. Moulding takes place with more difficulty than in vertex 
cases. 

3. The head is delayed longer at the brim, as extension 
has to be very marked before descent can begin ; hence, as a 
rule, labor is delayed. 

E.. M. P. : As this is probably the commonest position, its 
mechanism will be described in detail. 

The long diameter of the face, the frontomental, descends 
through the inlet in the right oblique diameter of the pelvic 
brim. The chin descends along the posterior pelvic groove 
on the right side till it strikes the pelvic floor, then it rotates 
forward through three-eighths of a circle on the right side of 
the pelvis till it comes under the pubic arch. The brow 
rotates into the hollow of the sacrum, and the frontomental 
diameter thus corresponds to the anteroposterior diameter of 
the outlet. The chin then appears at the vulva and escapes 
beneath the pubic arch. The movement of flexion then be- 
gins, the chin pivoting under the pubic arch, and the face, 
forehead, vertex, and occiput successively clear the perineum 
(Fig. 72\ The head now being free assumes its relationship 
to the shoulders, which occupy the right oblique diameter of 



218 PATHOLOGY OF LABOR. 

tlie pelvis ; the rest of the mechanism is the same as in a case 
of L. O. A. 

L. M. A. : The mechanism is the same as in a vertex case, 
except that the occiput is replaced by the chin, which pivots 

Fig. 72. 




Diagrammatic view of mechanism in a right mentoposterior position of a face 
presentation, chin rotating to pubes. 

under the pubes ; then the head is delivered by flexion. 
Sometimes in a large pelvis the head may be pushed through 
in extension without any special mechanism. 

In mentoposterior positions the head may descend into the 



MANAGEMENT OF FACE PRESENTATIONS. 219 

pelvis sufficiently far to prevent completely the anterior rota- 
tion of the chin, which is then forced into the hollow of the 
sacrum. This condition is practically fatal to the child, for 
the author has been able to find but one case recorded in which 
a living child was born after this accident had occurred. 

Head-moulding : The vault of the head becomes flattened 
and pushed backward ; the diameters lengthened are the 
occipitofrontal and the occipitomental ; the diameters short- 
ened are the suboccipitobregmatic and the cervicobregmatic. 

The caput succedaneum is found on the face, chiefly around 
the eye which lies anterior when the face is at the brim ; 
owing to the laxity of the tissues of the face the swelling is 
often very great and the discoloration considerable. The 
eye may be closed for days, and the child may be unable to 
suckle from the swelling of the lips. 

Prognosis. 

The foetal mortality in face cases is about 15 per cent. ; 
the maternal mortality is given as being over 6 per cent., 
for these cases are frequently mismanaged. The labor is 
tedious, as a rule. Anterior positions of the chin are better 
than posterior, as the labor is quicker. There is usually 
more or less serious laceration of the perineum. 

Management of Face Presentations. 

The important point in the first stage is to preserve the bag 
of waters intact as long as possible, because the face is a poor 
dilator of the cervix. The patient should therefore be kept 
in bed all through this stage. 

Flexion by Schatz's method: If the chin is posterior an 
attempt should be made to restore flexion and thus convert 
the position into a vertex anterior. This may be accomplished 
by gentle external manipulations according to the method 
recommended by Schatz (Fig. 73). The woman is placed in 
the Trendelenburg position, which may be accomplished by 
arranging an ordinary wooden chair (first sawing off* the legs 
close to the wooden seat) on the bed so that its back forms 
an inclined plane, covering it with a folded blanket and 



220 



PATHOLOGY OF LABOR. 



drawing the patient up over it so that her buttocks rest on 
the back edge of the seat. The operator then presses on the 
occiput of the cliiki with one hand, so as to force it into the 
pelvis, while he presses the other against the child's neck on 
the opposite side, thus flexing the head and straightening the 
vertebral column of the foetus. When flexion has thus been 
accomplished, pressure is then maintained upon the fundus, so 
as to force the head into the pelvic brim in the flexed position. 
If this be found impossible, the case may be left until the 
OS has dilated, when, after rupturing the membranes, an effort 



Fig. 73. 




Schatz's method of rectification by external manipulation, 

may be made to restore flexion by introducing the hand into 
the uterus. 

If it be found impossible to maintain the head in the 
flexed position after this manoeuvre, the forceps should be ap- 
plied and the head drawn down into the cavity in a flexed 
position, when the blades may be withdrawn and the delivery 
left to nature. 

If the patient is a multipara with lax parts and the uterine 
contractions are powerful, the case may be left to nature ; but 
care should be exercised to secure good extension as the head 
descends, in order that the chin may reach the pelvic floor in 
advance of the rest of the head. 

In a primipara in whom the presentation is posterior and it 



BREECH PRESENTATIONS. 221 

is found impossible to restore flexion, internal version may 
be employed. 

Forceps : If version be impossible in anterior positions 
where delay occurs at the brim, then forceps may be applied ; 
but the operation is difficult and dangerous, as the blades 
tend to slip off the head when traction is made. 

If all these efforts fail and the child has perished, then 
craniotomy must be performed to secure delivery 

When the head has passed the brim and fails to advance fur- 
ther, there is danger to the child from tension on the vessels of 
the neck causing engorgement of the cerebral circulation. In 
such cases the forceps slioidd be employed to hasten delivery. 

Symphysiotomy has been recommended in cases of persistent 
mentoposterior positions if the child is living. 

Brow Presentations. 

Many authorities describe a half-way stage in the develop- 
ment of face presentations. It can scarcely be classified as a 
special presentation, but should be considered as simply a dis- 
placement of the vertex. 

Should such a presentation be met with, it can only be diag- 
nosed by vaginal examination. The extension of the head is 
recognized by the fact that, instead of the vertex, the finger 
comes in contact with the brow ; possibly the anterior fonta- 
nelle may be distinguished, as well as the supra-orbital ridges. 

Treatment consists in the manual restoration of flexion ; 
and if this be impossible, version must be resorted to in order 
to effect delivery with a minimum of risk to the mother and 
child. In rare instances in which the brow is directed ante- 
riorly tlie head may descend to the pelvic floor in this partially 
extended condition ; in such cases the sinciput, being in 
advance of the rest of the head, is directed to the pubes, 
the root of the nose pivots under the pubic arch, and the head 
is delivered in flexion, precisely the same as has been de- 
scribed in speaking of '^face to pubes '' cases. 

BEEECH PEESENTATIONS. 

Definition : The presentation of any part of the pelvic pole 
of the foetal ovoid at the inlet is termed a breech presenta- 



222 



PATHOLOGY OF LABOR. 



tion. The term, therefore, includes a presentation of the but- 
tocks, kneeSy or fed. The denomination is taken from the 
position of the sacrum. 

Frequency : Breech presentations occur in the proportion of 
1 in 30 labors; if premature births be excluded, then the 

Fig. 74. 




Breech presentation. Right sacroposterior. Feet and cord in relation to os inter- 
num. (After A. R. Simpson.) 



proportion is about 1 in 60. The positions in order of fre- 
quency are : L. S. A. ; R. S. P. ; R. S. A. ; L. S. P. (Figs. 
74 and 75). 

Causes: Certain conditions favor presentation of the breech. 
These are : lax uterine or abdominal walls, excessive liquor 
aranii, uterine obliquity, multiple pregnancy, death or prema- 



DIAGNOSIS OF BREECH FRESENTATIOXS. 223 

turity of the foetus, placenta pravia, contracted pelvis, tumors 
of the uterus or neighboring structures, monstrosity, and 

hydrocephalus. 

Fig. 75. 




Breech presentation. Left sacro-anterior position. (After A. R. Simpson.) 

Diagnosis of Breech Presentations. 

Abdominal examination : On exploring the excavation of the 
pelvis it will be found empty, while at the brim a large, bulky, 
irregular, movable mass may be distinguished, Avhich is not 
engaged unless labor has well advanced. At the fundus the 
hard, well-defined contour of the head will be easily recog- 
nized. The foetal heart-sounds will be heard on the side to 
which the back is directed, at or above the level of the um- 
bilicus. 



224 PATHOLOGY OF LABOR, 

Vaginal examination : Care must be taken not to rupture 
the membranes if they be found intact, in making the vaginal 
examination. Generally the breech is situated so high up 
that it cannot be reached without risk of rupturing the bag 
of waters if the examination is made early in labor. After 
labor has advanced and the membranes have ruptured the 
breech may be recognized by feeling the sacrum, coccyx, and 
ischial tuberosities of the foetus. The anus may be recognized 
by the grasp of the sphincter ani, and l)y the presence of me- 
conium on the examining finger. If the child is a male, the 
scrotum and penis may be felt. Occasionally the former may 
be oedematous and may then be mistaken for the bag of Avaters. 
One or both feet may be felt; the foot may be distinguished 
from the hand by the projections of the heel and the malleoli. 
The knee may be distinguished from the elbow by the pres- 
ence of the patella and by the larger size. Care must be 
taken to distinguish the breech from the face, for which it is 
often mistaken. 

Mechanism of Breech Presentations. 

The first stage of labor is very prolonged, for the breech 
forms a poor dilator of the cervix, and on account of its soft- 
ness acts imperfectly as an irritator of reflex uterine contrac- 
tions. 

The breech descends generally with the anterior hip slightly 
in advance of the other. The anterior hip in striking the 
pelvic floor is rotated forward to the pubic arch, Avhere it be- 
comes fixed, while the trunk is driven down and the posterior 
hip moves forward ov^er the perineum (Fig. 76). Generally 
both hips emerge through the vulva at the same time, then 
follow the thighs and trunk. If the legs are flexed properly, 
they generally escape with the thighs and breech. 

The shoulders pass the brim with their long diameter trans- 
verse ; they then turn into the oblique, and finally, at the out- 
let, into the anteroposterior diameter. The anterior shoulder 
is generally delivered first, followed by the posterior. 

The head by this time, if flexion has been maintained by 
active external contractions, has entered the brim with its 
long diameter in the opposite oblique diameter of the pelvis 



MECHANISM OF BREECH PRESENTATIONS. 225 

to that in which the shoulders engaged. The occiput usually 
strikes the pelvic floor first and rotates to the front, while the 
face is directed to the hollow of the sacrum. The face and 
forehead are then born, followed by the rest of the head. 

Abnormalities in the mechanism: 1. The breech may be ar- 
rested at the brim or may not engage. This may be due 
either to pelvic contraction or to excessive size of the foetus. 

2. The breech may descend into the cavity of the pelvis 
and there be arrested. This may be due to excessive size of 
the foetus, to imperfect dilatation of the external os, to pelvic 
deformity, or to the extended position of the limbs along the 
body of the child preventing its lateral flexion. 

Fig. 76. 




Passage of buttocks over perineum in a breech case. (After Barnes.) 

3. The arms may become extended and cause arrest of the 
head at tlie pelvic brim. This accident may be due to an 
imperfectly dilated os or to pelvic contraction. It is very apt 
to occur if traction is made upon the body of the foetus to 
accelerate delivery. 

4. The head may become arrested at the brim or in the 
pelvic cavity, as a result of extension or from pelvic deformity. 
Occasionally when the face is directed anteriorly the chin may 
catch on the upper border of the pubes and cause delay. 

Moulding of the foetus : The breech is generally swollen and 
often discolored from ecchymoses ; the discoloration is generally 

15— Obst. 



226 PATHOLOGY OF LABOR. 

more marked over the anterior hip. If the child is a male, the 
scrotum is generally anlematous. 

Prognosis of Breech Presentations. 

The foetal mortality varies from 10 to 30 per cent., depend- 
ing upon the skill of the physician. The risks to the child 
are great, due to the prolapse of the cord and the pressure of 
the after-coming head upon it. Fractures and dislocations 
may be caused by efforts at rapid delivery. 

The risks to the mother are increased only by the tendency 
to laceration and to bruising of the soft parts on account of 
the necessity for rapid and sometimes violent extraction of 
the after-coming head. 

Management of Labor in Breech Presentations. 

General : A^ery early in labor, before the membranes have 
ruptured or the breech has become engaged in the brim, it 
may be possible to perform an external version. The opera- 
tion is not always practicable, and therefore should not be 
attempted unless there is certainty that it can be successfully 
accomplished. 

The position of the physician in charge of a breech case 
should be one of armed expectancy. As long as the natural 
processes are progressing satisfactorily he should be watchful 
but inactive, and should be prepared to interfere promptly on 
the appearance of danger to the child. 

When possible a skilled assistant should be obtained, whose 
duty it is to give the anaesthetic and attend to the maintenance 
of pressure upon the fundus, so as to prevent extension of the 
head during the delivery. 

Preparations should be made for treating asphyxia of the 
newborn infant. At hand should be placed, sterilized and 
ready for use, the ligatures for the cord, scissors, two pairs of 
artery-forceps (to be used instead of ligatures in cases in which 
speed is demanded), a basin containing warm sterile water in 
which are a couple of sterile towels for wrapping around 
the child's body during delivery, and the ordinary obstetric 
forceps. 



( 



MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 227 

Throughout labor the patient should be kept in bed, and 
should be cautioned against straining during the first stage, as 
it is desirable to retain the membranes without rupture as long 
as possible, to favor complete dilatation of the os uteri. The 
foetal heart-sounds should be frequently auscultated during the 
second stage of labor, since there is always danger of com- 
pression of the cord. Irregularity of the heart-beats is suf- 
ficient cause for interference. 

When delivery is imminent the patient should lie in the 
dorsal position, with the thighs flexed. In cases in which it is 
necessary to effect a speedy delivery the patient should be 
placed across the bed in the lithotomy position. As soon as 
the buttocks emerge they should be wrapped in a warm sterile 
towel, to prevent the child making efforts at respiration. 
From the moment the buttocks appear at the vulva till the 
placenta is delivered the fundus uteri should be constantly 
under the control of an assistant. The trunk, as it emerges, 
should be supported, so as to prevent undue strain upon the 
perineum and traction upon the after-coming head. As soon 
as the feet appear the legs may be gently drawn down in such 
a way as to make no traction upon the body of the child. 

As soon as the umbilicus comes within reach of the finger, 
a loop of cord may be gently drawn down and examined. If 
it is pulsating well, the case may be allowed to deliver slowly ; 
but sliould there be evidence of compression upon it, then the 
delivered portion of the child's body should be pressed back- 
ward and upward, and an attempt made to loosen the cord 
and to place it in one or other iliac fossa out of harm's way ; 
if this eflbrt fails, then delivery should be accomplished as 
speedily as possible. 

As the elbows appear at the vulva the arms should be 
drawn down, and then the child's body should be Avell ele- 
vated, so as to prevent the escape of the head. 

In the delivery of the head there is no need for rapidity in 
normal cases, when once the mouth and nostrils have cleared 
the perineum. These must be wiped off to prevent aspira- 
tion of mucus should the child attempt to breathe. Then the 
head should be delivered slowly and carefully, so as to avoid 
rupturing the perineum. 



228 



PATHOLOGY OF LABOR. 



Treatment of Arrest of Breech at the Brim. 

Arrest of the breech at the brim may be due to the excessive 
size of the child or to pelvic deformity. The precaution 
should always be taken of measuring the mother's pelvis, 
unless this has been done, before any operative measures are 
adopted. 

To secure descent five methods are available : (1) by 
bringing down the anterior leg ; (2) traction with a finger in 
the groin ; (3) the blunt hook ; (4) the fillet ; and (5) appli- 
cation of forceps. 

Traction after bringing down a leg : The hand, the palm of 
which corresponds to the abdominal aspect of the child, is 

Fig. 77. 




Breech presentation— legs extended. 



slowly introduced in the uterus, care being taken to ascertain 
the position of the foetal cord so as to avoid dragging it down. 
It is well also to press gently back the breech, so as to dis- 
engage it from the brim before seizing a foot. The anterior 
foot should always be selected, and when firmly grasped may 



3JAXA GEMEXT OF LABOR IX BREECH PRESENT A TIOXS. 229 

be gently drawn tlirough the os and vagina. Occasionally the 
legs may be found extended along the chest of the child (Fig. 
77). In such a case the foot may be brought within reach by 
passing two fingers along the back of the thigh, at the same 
time abducting it so as to press the knee to one side ; thus the 
foot tends to drop down in the median line of the chest, and 
may be grasped by slipping the fingers down along the leg. 
Provided there are no indications necessitating speedy delivery, 
the case may be left to nature as soon as the foot has been 
drawn down to the vulva. 

Should the patient be exhausted, delivery may be hastened 
by combined traction on the foot which has been brought down, 
and pressure on the fundus from above. The latter should be 
managed by the assistant, so that the operator may give his 
whole attention to the child. When it is desired to effect a 
speedy delivery the patient should be placed in the AValcher 
position, and when possible on a table. The foot should be 
grasped between the first and second fingers, and the line 
of traction should be downward and backward in the axis 
of the pelvic brim. When the leg is beyond the vulva it 
should be wrapped in a warm sterile towel, and then as much 
of the limb as possible should be grasped in the whole hand. 
The operator should introduce the forefinger of his free hand 
into the vagina and hook it into the posterior groin as soon as 
it comes within reach, in order to distribute the tractive force 
as widely as possible, and thus reduce the risks of injury to 
the child. As the breech distends the perineum it should be 
drawn forward against the pubes, so as to avoid laceration. 
As soon as possible the posterior limb should be gently drawn 
out, in doing this^ pressure on the thigh should be avoided, 
care being taken to seize the foot and draw down the leg in 
such a way that the knee comes down in the median line of 
the child's body. 

When it is impossible to bring down a foot it may be pos- 
sible to hook the forefinger in the groin, which may be done in 
any manner convenient to the operator. Traction may then 
be made downward and backward, care being taken to avoid 
pressure on the shaft of the femur, on account of the danger 
of its snapping. 

The blunt hook or fillet may be used as a tractor. The latter 



230 PATHOLOGY OF LABOR. 

should be used by preference as mucli less liable to do damage 
to mother or child. 

The fillet is usually composed of a strip of sterilized cotton 
or gauze bandage. The best instrument for placing the fillet 
is a gum elastic catheter. The catheter should be threaded 
with a loop of string and then, with its stilet, should be bent 
so as to form a large hook. After it has been sterilized the 
hook should be guided over the anterior hip and rotated so 
that its point passes between the child's thigh and abdomen. 
The finger should then be passed between the thighs, and the 
loop of string dragged down until the fillet can be threaded 
through it, when by withdrawing the catheter and string the 
fillet can be drawn into place. The line of traction should 
then be toward the child's sacrum, so as to avoid breaking the 
femur. 

As a last resort, should all other means fail, the forceps 
should be applied to the breech. 

Impaction in the Pelvic Cavity. 

When the breech becomes impacted in the pelvic cavity (Fig. 
78) it is generally impossible to draw down a leg. 

Traction may be exerted by hooking an index-finger into 
the groin ; or the fillet may be used. When these means fail 
forceps may be employed. If the child is alive and moderate 
traction with the forceps fails, then symphysiotomy may be 
resorted to. When the child has perished embryotomy is 
necessary. 

Rapid Extraction of the Trunk. 

As soon as the legs and the pelvis of the child have escaped 
from the vulva they should be wrapped in a warm towel and 
grasped with both hands in such a way that the thumbs of the 
operator lie along the sacrum, while the fingers seize the 
thighs. This gives the most secure grasp. Traction is then 
made downward and backward with both hands, while the 
assistant presses firmly on the fundus. As soon as the cord 
can be reached a loop should be drawn down, as is done in 
normal delivery of the breech. 

When the angles of the scapulae come into view the delivery 



MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 231 

of the arms should be attempted. To do this, two fingers of 
the operator's hand which corresponds to the arm it is desired 
to reach, should be passed up over the shoulder and down the 
arm to the elbow, which may then be swept across the chest 
so as to bring down the forearm and hand, the child's body 
being held in such a position as to give the greatest freedom 

Fig. 78. 




Delivery of child in a breech case bv traction made with fingers placed in groin. 
(After A. R. Simpson.) 

of movement pos.sible to the operator. Having released one 
arm, the operator should then change hands and deliver the 
other arm by a similar manoeuvre. 

Upward displacement of the arms : Not infrequently the 
arms are found to be displaced upward alongside the head. 
This is generally indicated by greater resistance to traction 



232 PATHOLOGY OF LABOR. 

after the scapulae have oome into view. When this complica- 
tion is found the body of the foetus should be pushed up in 
the axis of the brim, so as to diminish the pressure on the 
arms at that level. The body should then be rotated until its 
back is directed to one or other side of the mother. Usually 
the posterior arm is most accessible, and is therefore brought 
down first. Holding the child's body up against the pubes 
the operator presses two fingers up over the posterior shoulder 
to the elbow, and sweeps the arm doAvn across the face and 
chest, as directed above. Having released the posterior arm, 
the child's body is pressed over against the perineum, and the 
anterior arm is brought down by a similar manoeuvre. 

The anterior arm may be so firmly caught between the head 
and the pubes that it may be impossible to dislodge it. In 
this case it should be rotated so as to come into a posterior 
position. This rotation is accomplished by grasping the trunk 
of the child's body firmly with both hands, lowering it so as to 
bring its long axis to correspond to that of the pelvic brim, 
and then shoving it up so as to release the anterior arm from 
pressure. As soon as the arm is loose alongside of the head, 
the child is rotated about its long axis, so that the arm which 
has been anterior passes along the same side of the pelvis 
backward and rests in front of the sacro-iliac synchondrosis. 
By this manipulation the back is moved from one side to the 
front, and then to the opposite side. The arm is then deliv- 
ered as was the posterior arm in the first instance. Occasion- 
ally the anterior arm may be folded behind the occiput. In 
this case the revolution of the body must be made in the 
opposite direction. First turn the abdomen of the child for- 
ward and then to the opposite side, thus causing the shoulder 
to rotate through three-quarters of a circle. 

Constriction of the head by the cervix : Occasionally the 
cervix may become tightly constricted about the child's neck ; 
a condition which generally endangers the life of the child. 
The patient should be deeply anaesthetized, and traction made 
on the shoulders with one hand, while the fingers of the 
other, placed in the child's mouth, give what assistance is 
possible. 



MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 233 

Delivery of the After-coming Head. 

Deventer's method : Probably the easiest method of effect- 
ing a speedy delivery in a case in which the pelvis permits the 
descent of the head with the arms extended alongside is 
Deventer's. The body of the child is dropped downward, 
the feet are grasped with one hand, while the other presses 
upon the upper surface of the shoulders, the neck being be- 
tween the first and second fingers. Traction is made downward 
toward the floor, the patient being in the lithotomy position. 

Fig. 79. 




Anterior rotation of occiput. 



Thus the occiput appears at the vulva, the vertex slips under 
the pelvic arch, and the head is delivered in extension, being 
followed by the arms. This method is applicable only in cases 
in which the pelvic space is sufficient to permit the descent 
of the head and arms together. When the foetus is small, as 
in premature cases, this, in the experience of the writer, is 
the easiest and most rapid method of delivery. Contrary to 
expectation, laceration of the perineum is rare in cases in 
which this method of delivery is possible. 



234 PATHOLOGY OF LABOR. 

Arms Delivered — Head Still Retained. 

Having delivered the arms, the head being still retained, 
the operator has five methods of delivery at his disposal. 

1. The Smellie method : The body of the child having been 
wrapped in a warm towel, is placed on the flexor surface of 
the operator's left arm, the legs hanging on either side. The 
fingers of this hand are passed into the vagina, so that the 

Fig. 80. 




The Smellie-Veit method of extracting the after-coming head. (Doderlein.) 

tips rest on the fossa on either side of the child's nose. The 
finger-tips of the right hand are then placed on the child's 
occiput. Before making efforts at extraction the head is 
well flexed by pushing upward with the fingers on the occiput, 
and at the same time pulling down with the fingers on the 
face. Having secured good flexion, the operator pulls down- 
ward until the occiput is well under the pubic arch (Fig. 79), 
and then, but not till then, the trunk is raised, at the same 
time that traction is made so as to pivot the occiput under 



MAX A GEMEST OF LABOR IN BREECH PRESENT A TIONS. 235 

the pubic arch, and thus the face sweeps over tlie periueum 
and the head is delivered. Care must be exerted not to make 
traction with any degree of force once the head distends the 
perineum, otherwise the head will deliver with a snap and 
the result will probably be an extensive laceration. 

2. The Smellie-Veit or Mauriceau method : The child's body 
is placed on the operator's arm as described above, but one or 
two fingers are inserted into the mouth instead of on either 
side of the nose. The other hand is passed along the child's 
back until the middle finger rests on the occipital protuber- 
ance, while the index and ring fingers are flexed over the 

Fig. 81. 




The Wigand-Martin method of delivering the after-coming head. (Doderlein.) 

shoulders on either side of the neck (Fig. 80). Having 
loosened the head and secured good flexion, traction is then 
made with both hands at once, in the axis of the pelvic out- 
let, until the occiput pivots under the pubes ; then the child's 
body is carried upward toward the mother's abdomen, this 
movement being made very slowly and deliberately, to avoid 
laceration of the perineum. Care must be taken not to fract- 
ure or dislocate the lower jaw. 



236 



PATHOLOGY OF LABOR. 



3. Wigand-Martin method : The child's body is held on the 
left arm, tlie index-finger of the left hand being inserted into 
the mouth in order to fiex the head. The right hand is then 
placed on the mother's abdomen over the pubes, so as to 

secure a firm grasp of the head 
Fig. 82. (l^^ig- ^1)- Firm pressure is then 

made with the right hand in the 
axis of the parturient canal ; at 
the same time traction is made 
with the left hand, and as the 
head descends the child's body is 
elevated toward the mother's ab- 
domen. 

4. Prague method : Having wrap- 
ped the body in a warm towel, the 
operator seizes the child's feet with 
the right hand, the middle finger 
being placed between the internal 
malleoli, the index and ring fingers 
being above the external malleoli. 
The left hand is then placed on the 
child's shoulders in such a way as 
to secure a firm grasp (Fig. 82). 
Flexion is then made downward 
with both hands until the occiput 
appears under the pubes. Then 
the right hand swings the body 
upward, at the same time making 
traction, while the left hand is held 
firmly in position, being used as a 
fulcrum around which the head 
moves, until it is finally forced 
out of the parturient canal by 
this lever-like movement of the 

Prague grasp. body. 

The force exerted by this method 
is very considerable, and therefore it should be used only after 
the foregoing methods have been attempted. 

5. Forceps : Manual efforts at extraction having failed, the 
forceps may be used. To permit the application of the blades, 




TRANSVERSE PRESENTATIONS. 237 

the chilcFs head must be held up toward the mother's abdo- 
men by an assistant. Properly directed suprapubic pressure 
by an assistant increases the efficacy of all methods of deliv- 
ering the after-coming head. Six minutes is the maximum 
time at the operator's disposal once the placental circulation 
has been completely cut oif. Therefore it is advisable to have 
the assistant call off the minutes as the time passes, so that 
the last two may be utilized for the application of the forceps 
should recourse to these instruments be required. 

TRANSVERSE PRESENTATIONS. 

Definition : Any presentation of the trunk of the child's 
body is termed a transverse presentation. As the result of 
uterine action after the onset of labor transverse presenta- 
tions resolve into shoulder presentations. The term Gross- 
birth is frequently applied to a transverse presentation. 

Frequency : Less than 0.5 per cent, of all cases of labor 
present transverse presentations. 

Causes : The same causes that result in breech presentations 
also act in producing transverse presentations. 

Varieties : The long axis of the tnmk is very rarely trans- 
verse, but is usually obliquely placed as regards the long axis 
of the uterus ; thus any part of the foetus may present at the 
brim. 

Positions: Some writers classify transverse presentations 
according to the position of the lowest shoulder, making use 
of the scapula as the denominator ; e. g., S. L. A. ; S. R. P., 
etc. It is generally sufficient to classify the positions as 
follows : 

1 . Dor so-anterior : 

(a) Head on the right side of mother. 

(b) Head on left side (Fig. 83). 

2. Dorsoposterior : 

(a) Head on right side. 
(6) Head on left side. 
The most frequent position is dorso-anterior, head to the 
right side of the mother. 



238 



PATHOLOGY OF LABOR. 



Diagnosis of Transverse Presentations. 

Abdominal examination: On inspection the shape of the 
uterine tumor will be noticed to be abnormal. The longest 
diameter, instead of being vertical, will be found to be oblique, 



Fig. 83. 




Transverse presentation. Dorso-anterior, head on left side, arm prolapsed. 
(Farabeuf.) 

or even transverse. The head Avill generally be found in one 
or other iliac fossa, while it is impossible to explore the pelvic 
excavation from above, for the trunk, as a rule, completely 
fills the false pelvis. If the back is to the front, its smooth 



MECHANISM OF TRANSVERSE PRESENTATIONS. 239 

surface can be felt across the lower zone of the mother's abdo- 
men. If the back is directed posteriorly, the foetal limbs can 
be felt in front. The foetal heart-sounds are heard below the 
umbilicus, plainly when the back is to the front ; faintly, if at 
all, when the limbs are anterior. 

Vaginal examination : If the membranes are unruptured, no 
part of the foetus can be reached by the examining finger 
without great difficulty. Occasionally a limb or the prolapsed 
cord may be felt within the bag of waters. When the mem- 
branes have ruptured the finger may come in contact with an 
arm or the shoulder. The landmarks to be felt are the clav- 
icle, the humerus, and the spine of the scapula. The finger may 
be forced into the axilla and the ribs felt, thus distinguishing 
it from the groin. Very frequently in transverse presen- 
tations a hand is found prolapsed, which hand it is being 
distinguished by shaking hands with it. 

Prognosis. 

As spontaneous delivery is very rare in transverse presen- 
tations, the prognosis in cases left to Nature is very grave, 
both for the mother and the child. As artificial delivery is 
the rule in these cases, the prognosis depends on the length 
of time the case has been allowed to go on without treat- 
ment and the nature of the operative interference. 

The dangers to the mother are exhaustion, rupture of the 
uterus from thinning out of the lower uterine segment, risks 
of operative interference and of subsequent sepsis. 

Mechanism of Transverse Presentations. 

As a rule, natural delivery is impossible in transverse pres- 
entations, but in extremely rare instances Nature may effect 
delivery by one of th^ee methods : 

1. Spontaneous version : Uterine contractions may result in 
displacement of the foetus and its gradual version, so that its 
long axis finally corresponds to the long axis of the uterus. 
Thus the transverse presentation becomes altered to that of 
the breech or the head, the delivery then taking place accord- 
ing to the new presentation. Spontaneous version may take 



240 



PATHOLOGY OF LABOR. 



place before or after rupture of the membranes, and is more 
likely to occur in multiparse and when the child is living. 

2. Spontaneous evolution : This mechanism is favored by 
excessively strong uterine contractions, a roomy pelvis, and a 
small foetus. 

By the strong uterine contractions the anterior shoulder is 
forced down into the pelvis, and rotates to the front, while the 
head lies above the brim and over the pubes ; the breech and 
trunk are then compressed, and gradually forced past the 
head and anterior shoulder, which pivots on the pubic arch. 

Fig. 84. 




Spontaneous evolution. First stage. 



Thus the chest and breech slip past the shoulder, over the 
perineum, and are delivered. Finally the head enters the pel- 
vis and rotates, so that the occiput pivots under the pubic arch 
and the face sweeps over the perineum, thus completing the 
delivery (Figs. 84-88). 

3. Delivery with the body doubled up (Evolutio con duplicato 
corpore) : The conditions favoring this mechanism are strong 



I 



MECHANISM OF TBANSVEBSE PRESENTATIONS. 241 

Fig. 85. 




Spontaneous evolution. Second stage. 
Fig. 86. 




Spontaneous evolution. Third stage. 



16— Obit. 



242 



PATHOLOGY OF LABOR. 
Fig. 87. 




Spontaneous evolution. Fifth stage. 



MECHANISM OF TRANSVERSE PRESENTATIONS. 243 

uterine contractions, a roomy pelvis, and a small dead foetus. 
The presenting shoulder is driven down into the pelvis and is 

Fig. 89. 




Birth of child doubled. Evolutio con duplicato corpore. (Kleinwachter.) 



delivered first, the head and chest of the foetus are com])ressed 
together and forced through the canal, being thus delivered, 
and are followed by the breech and legs (Fig. 89). 



244 rATHOLOGY OF LABOR. 

Management. 

Transverse presentations should never be left to Nature to 
deliver. If seen early and the foetus is alive, version should 
be performed. 

If seen late, when impaction has taken place and the foetus 
has perished, then, if version cannot be easily performed, 
decapitation and evisceration should be done, so as to reduce 
the risk to the mother to the smallest possible limit. 



PROLAPSE OF THE FCETAL LIMBS. 

In Head Presentations. 

Any or all of the foetal extremities may prolapse alongside 
the head. 

The most common form of this accident is a prolapse of a 
hand, which, when it occurs, is found close to the temporal 
region. The worst form is when an arm lies across the back 
of the neck. 

Treatment. 

If the condition is discovered before the rupture of the 
membranes, an attempt should be made to overcome the d\^- 
Q\x\iy hy postural treatynent. The woman should lie on the 
side opposite the prolapsed extremity, with the hips slightly 
elevated. 

After the membranes have ruptured an attempt should be 
made to dislodge and push up the prolapsed extremity. To 
do this the woman should be placed as recommended above. 
Should the attempt fail ihefoixeps may be applied, care being 
taken to avoid including the hand in the grasp of the blades, 
and the head drawn down to the outlet. This very often 
causes the arm to slip up out of the way. Should it be found 
impossible to dislodge the arm sufficiently to apply the forceps, 
version may be carried out. 

When the condition is not discovered till the head is low 
down in the cavity, the forceps should be applied and the case 
terminated as rapidly as is possible. 



TWIN LABORS. 245 



In Breech Presentations. 

The prolapse of the hand is of no importance in breech 
presentations, and no attention need be paid to it. 



In Transverse Presentations. 

The prolapse of a foot is, of course, favorable. 

Should a hand or arm l)e found prolapsed, if it cannot be 
pushed up out of the way, it may be drawn down sufficiently 
to fasten a broad piece of tape about the wrist. After version 
has been performed the tape may be held so as to prevent the 
arm from rising alongside the head and complicating its 
descent. 

PLURAL BIRTHS. 

Twin Labors. 

These are usually easy and uncomplicated. 

Twin pregnancy occurs about once in 130 cases of gesta- 
tion ; while triplets occur about once in 5088 cases. 

The tendency to twin pregnancy is very frequently heredi- 
iary. The greatest number of reported cases have occurred in 
first pregnancies. 

According to the origin of the ova will arise the various 
peculiarities in the development of the placentae and mem- 
branes. 

If the two ova have been derived from separate Graafian 
follicles, each will have its own placenta, cord, chorion, and 
amnion, each being indej^endent of the other. 

Should the two ova have been derived from a single 
Graafian follicle, the amniotic sacs will be distinct, but the 
chorion and placenta will be in common, the two cords aris- 
ing from the same placenta. 

Usually twins arising from ova from a single Graafian 
follicle, are of the same sex ; while when the original ova 
are distinct each is of an opposite sex. Male twins are 
slio^htlv more common than female twins. 

Diagnosis : Very frequently the diagnosis of twins is not 
made until after the birth of the first child. The only certain 



246 PATHOLOGY OF LABOR. 

signs of twin pregnancy are the presence of two foetal heart- 
sounds, heard at different points over the abdominal surface, 
and having a different rhythm ; and the palpation of two dis- 
tinct heads. 

OtJier signs are, excessive size of the abdomen, with in- 
creased uterine distention, irregularity of the uterine outline, 
and the presence of a number of foetal extremities. 

Prognosis : The maternal prognosis is somewhat graver than 
in single births. The dajigers are : uterine inertia due to 
overdistention of the uterine walls; abnormal presentation ; 
albuminuria and eclampsia, more frequent in plural preg- 
nancies ; hemorrhage in the third stage of labor from trouble 
in the delivery of the placenta. 

The foetal prognosis is always more serious than in single 
births. The dangers are : deficient development from over- 
crowding in the uterus; malposition and malpresentation ; 
and hydramnios. 

Mechanism : The following table from Spiegelberg, based 
on 1138 labors, gives the combined presentations in their 
order of frequency. 

Both heads presenting 49.00 per cent. 

Head and breech 31.70 " 

Both pelvic presentations 8.60 " 

Head and transverse 6.18 " 

Breech and transverse 4.14 " 

Both transverse 0.37 " 

The order of delii^ery varies. When both heads present, 
usually the larger is delivered first. If one twin presents by 
the breech and the other by the head, usually the latter is 
delivered first ; if one presents transversely and the other 
longitudinally, the latter is usually expelled first. 

Management of labor: When the presentation of the first 
child is normal no special treatment is indicated. When the 
first child has been delivered and its respiratory function well 
established, before cutting the cord the physician should pal- 
pate the mother's abdomen to ascertain the position of the 
second child. If any abnormality exists, it should be at once 
corrected by external manipulations and the fundus uteri 
gently kneaded to stimulate retraction. The fundus may then 
be placed in charge of the nurse or assistant while the physi- 



TWiy LABORS. 247 

cian attends to the cord of the first child. This should be 
tied in two places and then divided between the ligatures, in 
case there should be communication between the placental 
circulations and the second child bleed to death. 

Friction on the fundus should be sustained until the uterine 
contractions are firmly established. It is not advisable to 
wait more than half an hour for the birth of the second child. 
The second amniotic sac should then be ruptured and the 
uterine contractions reinforced by firm pressure on the fundus 
so as to expedite the delivery of the second child. 

From this time until retraction has been firmly established, 
after the complete emptying of the uterus, the fundus should 
be kept constantly under control in order to prevent its relax- 
ation and the occurrence of hemorrhage. 

Should hemorrhage follow the delivery of the first child, 
the second should be delivered as rapidly as possible, either 
by forceps or version, and the uterus emptied artificially. It 
is not advisable to inform the mother during labor, should a 
diagnosis of twins be established, as the shock may inhibit 
uterine action. 

Complications of Twin Births. 

Compound presentations : Occasionally both foetuses tend to 
engage simultaneously in the brim. AVhen both heads tend 
to present at the same time, the highest should if possible be 
pushed up, and the forceps then applied to the lower head 
and traction exerted until it is firmly engaged. During the 
traction an assistant may be able to hold the head of the other 
child out of the way, by pressure on the abdominal wall of 
the mother. 

"When the head of one child and the breech of the other 
tend to engage at the same time, the breech should be pushed 
up and the head drawn down. 

AVhen foetal extremities are found to present along with a 
head, they should be replaced and the head drawn down by 
means of the forceps. 

Interlocking twins: Occasionally both heads enter the 
pelvis, one being generally well in advance of the other. The 
upper head then becomes jammed against the neck and thorax 
of the first child. 



248 PATHOLOGY OF LABOR. 

Treatment: The most advanced head should be delivered 
by forceps, as unlocking is generally out of the question. 
The second head should then be delivered, and when this is 
done the body of the first child may be extracted, the head 
of the second being held out of the way by an assistant. 

Sometimes it is necessary to perforate one of the heads in 
order to permit the delivery of the other. When this opera- 
tion is required it should be performed on the head of the first 
child, because the second is more likely to be alive, there being 
less risk of compression of its cord. 

In cases in which the breech of one child and the head of the 
other become impacted in the pelvis an endeavor should be 
made to push up the head and deliver the breech. The body 
of the child presenting by the breech should only be delivered 
as far as the neck, as the two heads usually become locked at 
the brim by the overlapping of the chins or of the occiputs, or 
by the face of one child being pressed against the back of the 
other child^s neck. 

Should it be impossible to push back the head of the second 
child or to apply forceps and deliver it, the head of the breech 
child should be perforated and extracted before attempting to 
deliver the other. 

Triplets. 

As a rule no difficulty is encountered in the delivery of trip- 
lets, as the greater the number of foetuses the greater the 
tendency to prematurity of delivery. 

The labor is generally prolonged on account of delay in 
the first stage from imperfect uterine contractions. 

The third stage must be very carefully managed, and it is 
advisable to empty the uterus artificially in order to insure 
that no portions of placenta are retained. 

DYSTOCIA DUE TO ANOMALIES OF FCETAL 
DEVELOPMENT. 

Overgrowth of the Foetus. 

Definition : A child may be said to be overgrown when it 
weighs eleven pounds, or over, at the time of birth. It is but 
very seldom that a child is born weighing twelve pounds ; but 



PREMATURE OSSIFICATION OF THE SKULL. 249 

cases are recorded in which the birth- weight was over twenty 
pounds. 

Cause : Nothing definite is known as to the cause of 
this overgrowth. Multi parity, advanced age of one or both 
parents, and prolongation of pregnancy are generally regarded 
as the probable causes. 

Mechanism : When the head presents in these cases it 
generally enters the pelvis in extreme flexion. Moulding is 
generally very marked as the result of a prolonged second 
stage. 

Treatment. 

The best treatment is prophylactic. When the condition is 
suspected, which is rare, a careful palpation should be made 
and the size of the head estimated. The head should then 
be forced into the brim by the pressure from above, to give 
one an approximate idea of the relative size of the pelvis. If 
it be found that it is a tight fit, then labor should be at once 
induced, as no advantage can be gained by waiting on nature. 

When the condition is not discovered until labor, then the 
proper course to pursue is to support the patient's strength 
and control the pains by means of hypodermics of morphine as 
often as required, until the head has had time to mould thor- 
oughly, when forceps may be applied and an attempt made to 
deliver the child. Care should be taken to avoid excessive 
force in traction. 

If no advance is made, and the child is alive, symphysiotomy 
is then necessary. 

When the condition is recognized early and the disproportion 
between the head and the pelvis is not marked, inteimal ver- 
sion may offer the child a greater chance of life than a high 
forceps operation. The choice of operation depends in great 
measure on the skill of the operator in performing the one or 
the other. 

If the child has perished, embryotomy should be the operation 
of choice. 

Premature Ossification of the Skull. 

Premature ossification of the bones of the skull, causing 
more or less obliteration of the sutures and fontanelles, greatly 



250 PATHOLOGY OF LABOR. 

modifies the moiildability of the head, and may thus lead to 
delay in labor. 

Position : The head may be arrested at the brim or in tlie 
cavity. 

Treatment : Forceps or symphysiotomy may be necessary to 
secure delivery of a living child. 

Hydrocephalus. 

This is probably the commonest cause of excessive size of 
the foetal head. 

Etiology : The condition is due to the accumulation of the 
serum in the ventricles of the brain. The accumulation of 
fluid may be so great as to cause obliteration of the cerebral 
convokitions and excessive thinning of the cranial bones, 
which become widely separated. From the excessive size of 
the vault the face appears small. Spina bifida or some other 
malformation is generally present in these cases. 

Diagnosis : In about a third of all cases of hydrocephalus 
the breech presents. The condition should always be sus- 
pected when in vertex presentations the head fails to engage 
in the brim, although the pelvis is normal in size and no 
good reason can be found for the delay. 

By abdominal examination the gaping fontanelles and 
sutures may be made out and fluctuation may be obtained in 
these regions. The cranial bones may be felt to be excessively 
thin, and pressure on them may give the sensation of crepita- 
tion. The head is felt to be enlarged and soft. 

These conditions may be better felt by a bimanual examina- 
tion when this is possible. 

Prognosis : The life of the child is to be considered as of 
little moment, for should it survive birth death generally 
takes jilace shortly after. 

Death of tlie mother may result from exhaustion or from 
rupture of the uterus. The rupture generally occurs in the 
lower segment, which becomes greatly stretched and thinned. 

Treatment : When the head presents (Fig. 90), it should be 
perforated and the fluid permitted to drain away. When the 
head collapses delivery may be effected either by version or 
by means of a cranioclast. 



HYDROCEPHAL US. 



251 



Forceps should never be applied to a hydrocephalic head 
if the condition is at all marked, as it is impossible to secure 
a good grasp on account of its compressibility. 

When the breech presents, the trunk and arms may be ex- 
tracted and an attempt made to perforate the cranial vault by 



Fig. 90. 




Thinning of lower segment of uterus in obstruction from hydrocephalus. 
I After Bandl.) 



the temporal fontanelle. If this cannot be reached, then the 
spinal canal should be opened in the dorsal region by means 
of a pair of scissors, and a catheter passed through it into 
the cranial cavity and the fluid thus evacuated (Van HuevePs 
method: Fig. 91). 



252 



PATHOLOGY OF LABOR. 

Fig. 91. 




Puncture of spinal canal in a case of hydrocephalus obstructing labor. 

(After Herrgot.) 

Encephalocele ; Meningocele ; Hydrencephalus. 

These conditions when present do not often seriously com- 
plicate labor, as the tumors are either small or are so situ- 
ated that they fail to affect materially the progress of the 
case. If obstruction to labor occur, the growth should be 
perforated, when its contents will drain away and make de- 
livery possible. 

Tumors of the Foetal Trunk. 

Certain tumors arising in connection with the foetal trunk 
may by their bulk or situation induce dystocia. 



DYSTOCIA DUE TO ABNORMALITIES, ETC. 253 

Varieties : Spina bifida ; teratomata situated on the spine, 
jaw, or orbit ; hydrothorax ; ascites ; cystic degeneration of 
the kidneys ; malignant conditions of the liver, spleen, or 
pancreas ; distention of the urinary bladder, and hernia of 
viscera through clefts in the abdominal or thoracic walls, may 
be mentioned under this heading. 

Treatment : Should delivery be delayed, forceps or version 
may be resorted to, or some form of embryotomy. Tumors 
with fluid contents should be evacuated. 

Monstrosities. 

Anencephalus or hemicephalus is the form most commonly 
met with. Delay is generally caused in the first stage by the 
absence of the head as a dilator. When the diagnosis is 
made, version, if possible, should be performed. 

Double monsters : These may very seriously complicate 
labor; but, as a rule, the foetuses are small and delivery 
occurs naturally. In difficult cases craniotomy or some other 
form of embryotomy is necessary to effect delivery. 

DYSTOCIA DUE TO ABNORMALITIES OF THE F(ETAL 
APPENDAGES. 

Short cord : Cases have been recorded in which the cord 
has not measured more than two inches in length. Relative 
shortness of the cord may occur from its coiling around the 
neck and limbs of the foetus. 

The condition may lead to premature detachment of the 
placenta, rupture of the cord, or compression of its vessels 
from stretching, which results in death of the foetus. 

The diagnosis is difficult. Sometimes the patient com- 
plains of marked pain at the placental site during each con- 
traction. Occasionally a portion of the uterine wall may be 
felt to be drawn downward and inward during each contrac- 
tion. Frequently the presenting part is retracted rapidly as 
the uterine contraction subsides. 

Treatment consists in rapid delivery with the forceps or by 
version. 



254 PATHOLOGY OF LABOR 

Prolapse of the Cord. 

A loop of the umbilical cord may prolapse alongside or in 
front of the presenting part. As labor progresses the cord 
is exposed to pressure between the presenting part and the 
pelvic wall, which results in interruption of the foetoplacental 
circulation, and possibly in the death of the foetus. 

Prolapse of the cord may occur either before or after rupt- 
ure of the membranes. 

Frequency : This accident occurs once in about 250 cases of 
labor. It is met with most frequently in presentations of 
the pelvic pole of the foetus. 

Etiology : The essential cause of prolapse of the cord is 
failure of the presenting part of the foetus to fill, completely 
and continuously, the lower segment of the uterus. 

The foetal conditions which predispose to this accident are: 
malpositions and malpresentations ; small size and increased 
mobility of the foetus ; anomalies of other fcetal appendages, 
as marginal insertion or excessive length of the cord, hydram- 
nios, placenta prsevia ; and sudden escape of the liquor amnii 
with the patient in the erect position. 

The predisposing maternal conditions are : pelvic deformity ; 
relaxed abdominal wall, as in some multiparae ; uterine and 
other tumors ; uterine obliquity. 

The accident is also more liable to occur in cases of multi- 
ple pregnancy. 

Diagnosis. 

Before the rupture of the membranes it is a somewhat diffi- 
cult matter, as a rule, to recognize a prolapse of the cord on 
account of its non-resisting nature and the ease with which 
it recedes before the examining finger. 

After rupture of the membranes it may be generally recog- 
nized without difficulty, on account of its twists and the pulsa- 
tions of its vessels. 

It has been not infrequently mistaken for a prolapsed loop 
of intestine ; and occasionally a portion of intestine has been 
mistaken for the cord. Care in examination should make 
such an error in diagnosis impossible. 

The position the cord usually occupies is at one or other 



PROLAPSE OF THE CORD. 255 

side of the pelvis somewhat posteriorly ; rarely it may lie 
either in front of the promontory or behind the symphysis 
pubis. 

When the foetal heart- sounds grow progressively weaker 
and no cause is apparent, prolapse of the cord should be 
suspected and appropriate treatment inaugurated. 

Prognosis. 

This complication rarely influences the prognosis for the 
mother, save in so far as the operative treatment exposes her 
to risks of shock and sepsis. 

For the child the prognosis is somewhat grave, the mortality 
rising to somewhat over 50 per cent. The cause of foetal 
death is occlusion of the foetoplacental circulation from press- 
are on the cord. This pressure results in asphyxiation of 
the child. Should the prolapsed portion of the cord show an 
absence of pulsation for ten or fifteen minutes, and abdominal 
auscultation fail to permit the detection of heart-sounds, the 
death of the foetus is assured. 

Treatment. 

If the child has perished, no treatment is indicated, and 
the case may be left to Nature. 

Before rupture of the membranes : The indications for 
treatment are to prevent rupture of the membranes as long as 
possible, and to favor the replacement of the cord by appro- 
priate posturing of the patient. The woman should be made 
to adopt the genupectoral posture (Fig. 92). While the 
patient is in this position the influence of gravity causes the 
cord to settle slowly toward the fundus, and thus the pro- 
lapsed loop is gradually withdrawn. During the intervals be- 
tween the pains this may be gently pushed back with the 
hand, care being taken not to rupture the membranes. When 
the condition has been correeted, the patient may be permitted 
to recline on the side opposite to that occupied by the cord. 
The change of position should be made slowly and carefully, 
so as to avoid forcing the cord down again. The membranes 
may then be ruptured, care being taken to force the head 
down by pressure from above while this is being done. 



256 



PATHOLOGY OF LABOR 



After rupture of the membranes : Before attempting to re- 
place the prolapsed loop of cord after rupture of the mem- 
branes, care should be taken to find out whether the child is 
alive. If pulsation has ceased in the cord, the heart may still 
be beating ; if this is the case, the presenting part should be 
pushed up, and the cord replaced after pulsation returns. 
^ The woman should be placed in the Sims position on the 
side opposite to the prolapsed cord. The hips should be ele- 
vated by means of a folded pillow. The operator should then 
push back the presenting part so as to release the cord. This 



Fig. 92. 




Postural treatment of prolapse of the cord. 



may then be loosely twisted, care being taken not to interfere 
with its pulsations, and the twisted mass gently pushed up 
beyond the presenting part. 

If it be found impossible to replace the cord with the woman 
in the Sims position, she should be placed on her knees and 
chest and another attempt made, if necessary giving an anaes- 
thetic so as to relax the uterus completely. Tlie objection 
to the knee-chest position is the tendency for air to enter the 
uterine cavity ; if this accident occurs, the subsequent labor 
should not be unduly prolonged. 

Should manual efforts fail, a suitable instrument for replac- 



PROLAPSE OF THE CORD. 



257 



mg the cord may be improvised with a No. 10 or No. 12 gum 
elastic catheter and some tape. A loop of tape is made to 
encircle the cord loosely, and its free ends are attached to the 
tip of the catheter. The catheter, with its stylet inserted, is 
then pushed well up into the uterus, carrying the cord with it 
(Figs. 93, 94, and 95). The stylet is then withdrawn and the 



Fig. 93. 



Fig. 94. 





Reposition of cord. 
(Witkowski.) 



Braun's reposition of cord. 
(Witkowski.) 



catheter left in the uterus to come away with the child. Care 
should be taken to remove the bone button from the end of 
the catheter. 

If all attempts at reposition of the cord fail, then either 
version or forceps, with rapid delivery, must be resorted to 
in order to save the life of the child. Before either of these 
operations the loop of the cord should be placed opposite the 
sacro-iliac joint, where it will be least pressed upon. 

17— Obst. 



258 



PATHOLOGY OF LABOR 



Coiling of the Cord about the Foetal Neck. 

Quite frequently the f(ietal cord is found to be coiled about 
the neck of the child. It may encircle the neck several times, 
and thus produce a relative shortening 
Fig. 95. of the cord. 

The condition is difficult to diagnose 
before delivery of the head. It may 
be suspected if the head descends well 
with each pain, but rapidly recedes in 
the interval between the contractions. 

Results : Occasionally the traction is 
so severe as to interfere with the foeto- 
placental circulation ; and has been 
known to cause premature detachment 
of the placenta. 

The only treatment that can be sug- 
gested is the application of the forceps 
and the rapid delivery of the head ; 
when the cord may be cut and un- 
coiled from the neck before the birth 
of the trunk takes place. 

Placenta Praevia. 

The placenta is normally implanted 
entirely within the upper uterine seg- 
ment. 

When it is implanted, in whole or in 
part, upon the lower uterine segment the 
condition is known as placenta praevia. 

Varieties : Three varieties are de- 
scribed : 

(1) Placenta praevia centralis: The 
placenta is so situated that its centre 
corresponds with the internal os (Fig. 
96). 

(2) Placenta praevia marginalis : The 
placenta is situated so that but a portion of its margin over- 
laps the internal os (Fig. 97). 

(3) Placenta praevia lateralis : The placenta is situated on 



Another method of reposi 
tion of cord. 



PLACENTA PREVIA. 



259 



the lateral wall of the uterus, extending well down into the 
lower segment, but not reaching as far as the internal os 
(Fig. 98). 

In the central and marginal varieties the hemorrhage may 
begin early in pregnancy ; it is repeated frequently, and in 
labor is much more serious than in the lateral variety. 

Fig. 97. 





Placenta prsevia centralis. Placenta prsevia marginalis. 

Fig. 98. 




Placenta praevia lateralis. (After Dakin.) 



Freciuency : Placenta pra^via centralis is very rare ; lateral 
and marginal placenta praevia are the commonest varieties. 
Placenta prsevia occurs about once in 1000 cases. Tt is more 
frequently met with in multiparse than in primiparse. 

Etiology: A satisfactory explanation of the occurrence of 



260 PATHOLOGY OF LABOR. 

placenta praevia has never been advanced. Chronic inflamma- 
tory changes in the mucous membrane certainly predispose to 
its occurrence. Other probable causes are : subinvolution, 
atrophy of the decidua, new growths, and malformations of 
the uterus. 

Symptoms and Physical Signs. 

The symptoms of placenta prsevia do not usually present 
themselves until after the sixth month of pregnancy. 

The first indication of the condition is a sudden gush of 
blood from the genitals, usually without apparent cause and 
without pain. The bleeding then recurs at intervals as preg- 
nancy advances. The amount of blood lost is proportionate 
to the extent of the placental separation. When hemorrhage 
takes place during pregnancy it is probably due to a partial 
separation of the placenta in the lower uterine segment, Avhere 
its attachment is imperfect. This separation is caused by the 
normal uterine contractions which constantly occur through- 
out pregnancy. 

The first hemorrhage when it occurs during labor may be so 
severe as to threaten the patient's life. As a rule, the bleeding 
is most profuse in the intervals between the pains ; but this 
cannot be said to be diagnostic of the condition. 

By abdominal examination the location of the placenta may 
be recognized, when the implantation is on the anterior uterine 
wall, by feeling its edge, which presents as a resisting ring. 
Below this point the uterus feels soft and boggy, and the foetal 
parts can only be felt indistinctly, while elsewhere they may 
be readily made out. Over this boggy area the placental bruit 
is to be heard with great distinctness. If the larger portion 
of the placenta occupies the lower uterine segment, malpres- 
entations of the fretus may occur, as the presenting part is 
thus prevented entering the pelvic brim. 

By vaginal examination the cervix and lower uterine seg- 
ment are found to be softer than usual. If the insertion of 
the phicenta is marginal, one side of the cervix and lower seg- 
ment may be softer and more boggy than the other. Pul- 
sating vessels may be felt around the cervix. 

The external os is usually patulous, and through it the 
finger may be pushed till the internal os is reached, where the 



PLACENTA PRMVIA. 261 

maternal surface of the placenta may be felt, a gritty feel dis- 
tinguishing it from a blood-clot or the membranes. 

Diagnosis. 

When hemorrhage takes place in the later months of preg- 
nancy a careful examination should be made to ascertain its 
cause. The rupture of a varicosed vein in the vagina and 
premature detachment of the normally situated placenta may 
lead to severe hemorrhage in the later months of pregnancy. 
A careful and systematic examination will generally permit a 
diagnosis to be made. 

Treatment of Placenta Praevia. 

The control of hemorrhage is the principal indication of 
treatment. 

In the rare cases in which the condition of placenta prsevia 
is recognized before the foetus is viable it may be possible to 
carry out an expectant plan of treatment until the seventh 
month of the pregnancy is reached. The patient must be 
kept in bed, not being permitted to rise for any purpose. It 
may be well to administer chloral (gr. xv) or liq. opii sed. 
(trixv) two or three times daily to control the nervous system. 

When the seventh month has been reached labor should be 
induced, as after this period the woman may bleed to death 
before medical aid can reach her. 

Being satisfied that the condition of placenta prsevia is 
present, it is the duty of the physician at once to empty the 
uterus if the child is viable. 

The patient should be anaesthetized and placed in the 
lithotomy position, with her hips at the edge of the bed. A 
Kelly pad should be placed under her. The vulva and vagina 
should then be scrubbed and douched with formalin or bi- 
chloride solution. The operator having sterilized his hands 
and arms, should then dilate the cervix by inserting one 
finger, then a second, and then the thumb of the right hand. 
Search should then be made for the edge of the placenta. If 
the placenta is lateral or marginal, it may be sufficient to 
rupture the membranes, tearing them freely, and to sweep the 



262 PATHOLOGY OF LABOR. 

fingers round under the margin of the placenta so as to sepa- 
rate it from the uterus for a short distance. The fingers may 
then be withdrawn if the head of the foetus is presenting. 
Firm pressure on the fundus, so as to crowd the head into the 
pelvis, may then be sufficient to control the hemorrhage ; if 
so, the case may now be left to Nature. If the os has been suf- 
ficiently dilated, the forceps may be applied and the head 
drawn down, after which the case may be left to Nature to 
deliver. 

If the placenta is central, or if a considerable portion of the 
placenta is found over the internal os, the proper treatment is 
to perform internal version. A foot is seized and drawn 
down until the hemorrhage is checked. From time to time 
the protruding leg may be drawn upon to hasten dilatation of 
the cervix. Plenty of time must be allowed for the cervix to 
dilate completely, otherwise there will be difficulty in extract- 
ing the after-coming head. 

If there has been a great loss of blood and the cervix is 
found to be rigid, it is better to pack the cervix and vagina 
with sterile iodoform gauze, which may be left in place until 
the patient has had time to rally under appropriate treatment 
(see Post-partum Hemorrhage). The gauze tampon not only 
checks the hemorrhage, but also assists in softening and di- 
lating the cervix and os. 

Many authors recommend the employment of hydrostatic 
dilators instead of the gauze tampon. The Champetier de 
Ribes bag is the best for this purpose. It is claimed that the 
bag controls the hemorrhage and dilates the cervix more effiict- 
ually than does the vaginal packing, while it as a rule causes 
less discomfort to the patient. For the introduction of the bag 
the patient is placed in the lithotomy position, the anterior lip 
of the cervix is seized with a tenaculum and drawn well 
forward, being then held by an assistant. The dilating bag is 
folded into a cylinder, grasped w^ith a pair of forceps, and 
guided carefully into the cervix and through the internal os. 
Before withdrawing the forceps the distention of the bag 
should be commenced by injecting into it boiled water by 
means of a syringe attached to the tube of the bag. Then as 
the bag distends the forceps may be unlocked and carefully 
withdrawn. As a precaution against rupture of the bag, the 



PREMATURE SEPARATION OF PLACENTA, 263 

operator should ascertain beforehand how many bulbfals of 
water are required to dilate it completely. 

The most rigid precautions as regards asepsis should be 
observed in the treatment of placenta prsevia, as the risk of 
infection is greater than in ordinary cases, on account of the 
low position of the placental site. 

After the child has been delivered the operator should intro- 
duce his hand into the uterus to remove the placenta and any 
clots that may be found there. This sliould be followed by a 
prolonged hot intra-uterine douche of sterile salt solution or 
1 : 500 formalin. A full dose of the fluid extract of ergot 
should be administered as soon as the uterus is emptied, or 
else a hypodermic of ergotin. 

Prognosis : Placenta prsevia constitutes a most serious com- 
plication of pregnancy or labor for both mother or child. 
Under prompt and aseptic treatment the maternal mortality 
should be practically nil. As premature delivery is frequent, 
the infant mortality-rate is high. 

Premature Separation of a Normally Situated Placenta : 
Accidental Hemorrhage. 

The hemorrhage associated w^th premature detachment of 
a normally situated placenta is termed '* accidental," to dis- 
tinguish it from the ^' unavoidable " hemorrhage of placenta 
prsevia. 

Varieties : Accidental hemorrhage may be apparent or con- 
cealed. 

In apparent accidental hemorrhage the blood dissects its 
way between the membranes and decidua, and escapes through 
the cervix. 

In concealed accidental hemorrhage the blood fails to find 
a^ way of escape, and may collect within the uterus in suffi- 
cient quantity to cause serious symptoms, or even death of the 
patient. 

In this form any of the following conditions may obtain and 
prevent the escape of blood : 

1. The placenta may be detached only at the centre, the 
margin remaining adherent ; 



2()4 



PATHOLOGY OF LABOR 



2. The upper margin may be detached, so that blood accu- 
mulates between the membranes and the uterine wall ; 

3. A portion of the edge 
Fig. 99. of the placenta and of the 

adjacent membranes may be 
detached ; the latter may 
rupture and permit the blood 
to mingle with the liquor 
amnii in the sac. 

4. The cervix may be ob- 
structed by a clot, the de- 
tached membranes, or the 
presenting part of the foetus 
(Fig. 99). 

Etiology: The predispos- 
ing causes may be given as, 
tubercular and syphilitic de- 
generation of the decidua, 
placental degenerations, ne- 
phritis, ansemia, and the 
acute infectious diseases. In 
the presence of these but a 
trivial exciting cause is re- 
quired to produce separation 
of the placenta. A sudden 
jar, a blow on the abdomen, 
or violent muscular exertion 
may be all that is required 
to brinff about such a separa- 

Frozen section of the uterus of a ,. '^ '■ 

woman who dierl of accidental hemor- tion. 
rhage at the Maternlte de Beaujon. 
(Pinard and Varnier.) 




Symptoms and Diagnosis of Accidental Hemorrhage. 

The symptoms resemble those of rupture of the uterus, 
but are not so severe. 

In the apparent variety the fact of hemorrhage is obvious. 
It usually takes place early in labor or during the later 
months of pregnancy. Severe localized pain at the placental 
site is not infrequent. The uterus may bulge at this point. 



PREMATURE SEPARATION OF PLACENTA. 265 

Placenta prsevia is readily distinguished by a careful vaginal 
examination. 

Concealed hemorrhage is generally revealed by the systemic 
effects. Rapid pulse, pallor, cold extremities, restlessness, 
sighing respiration, and collapse may be present. If labor 
has begun, the uterine contractions cease or become weak, 
though the patient may complain of more or less continual 
pain at the placental site. On abdominal examination the 
uterine wall may be found bulging at the seat of the hemor- 
rhage and the foetal heart-sounds are feeble and irregular. 
Rupture of the uterus may be distinguished from concealed 
accidental hemorrhage by the fact that the former occurs late 
in labor, usually after rupture of the membranes, and that the 
presenting part of the foetus recedes. 

Prognosis. 

In apparent hemorrhage the prognosis is good for the 
mother, but not favorable for the child. If labor does not 
come on at once, there is danger of infection of the blood- 
tract between the edge of the placenta and the os, resulting 
in sepsis. 

In the concealed hemorrhage the percentage of mortality for 
both mother and child is high. Death results from hemor- 
rhage, shock, extreme anaemia, or sepsis. The foetal mortality 
is due to interference with the uteroplacental circulation. 

Treatment. 

External variety : If the external hemorrhage is moderate 
in amount, a full dose of opium (liq. opii sed., TTLxxv) and 
rest in bed for a few days will be the only treatment required. 
The patient's temperature should be taken twice daily for a 
week or ten days, and if evidences of infection of the blood- 
tract occurs the uterus should be emptied. When the blood- 
loss is alarming it may be necessary to induce labor. The os 
should be dilated digitally to permit rupture of the mem- 
branes. A Barnes or Champetier de Ribes bag may then be 
introduced into the cervix and left there till it is expelled, 
when forceps may be applied, should the forces of Nature fail 
in promptly effecting delivery. When it is required to empty 



266 PATHOLOGY OF LABOR. 

the uterus immediately, the cervix sliould be dilated rapidly ; 
if necessary, it should be incised and version performed. 

Concealed variety : If the patient's condition is such as to 
forbid active obstetric interference, the treatment should be 
directed to combating the effects of the shock and hemor- 
rhage (see Treatment of Post-partum Hemorrhage). 

Tiie fundus should be compressed by means of a snugly 
fitting binder and pad. The foot of the bed should be ele- 
vated. 

AVhen the patient's condition permits, the uterus should be 
emptied by means of manual dilatation of the cervix and ver- 
sion. The placenta in these cases should be removed manu- 
ally, and a hot intra-uterine injection should be given after 
the uterus has been emptied. 

The after-treatment should be directed to controlling the 
effects of severe hemorrhage, and to securing good uterine 
contraction. 

Retained Placenta. 

This condition is of frequent occurrence. The placenta is 
usually completely detached, and lies in the dilated lower 
uterine segment or in the upper part of the vagina. 

Causes : Feeble uterine contractions, or, more frequently, 
improper methods of placental expression, generally give rise 
to the condition. A full bladder or rectum may lead to reten- 
tion of the placenta. 

Treatment : The proper application of Crede's method of 
expression is usually all that is required in the way of treat- 
ment. The uterus may be steadied and held in position by 
laying one hand across the suprapubic region of the abdomen, 
while the other firmly squeezes the fundus and at the same 
time exerts pressure in the axis of the pelvic inlet during a 
uterine contraction. This method will rarely fail to secure ex- 
pulsion of the placenta. Very occasionally it may be neces- 
sary to introduce a couple of fingers into the vagina, so as to 
reach the lower edge of the placenta and hook it forward. 

Adherent Placenta. 

In this condition, which is rare, the placenta is not only 
retained, but is also adherent to the uterine wall. The adhe- 



A DHERENT PL A CENT A . 



267 



sion is rarely complete ; a part of the placenta is usually 
detached. The torn sinuses bleed profusely, as the uterus 



Fig. 100. 




Artificial removal of adherent placenta. (Modified from Ribement-Dessaignes and 

Lepage ) 



cannot contract properly on account of the portion of the 
placenta which remains adherent. 

Causes : The most frequent cause is a placentitis (or de- 
cidual inflammation) of specific origin. Chronic endometritis 



268 PATHOLOGY OF LABOR. 

and placental degenerations, due to clironie nephritis in the 
mother, may give rise to adherent placenta. 

Treatment : If Credo's method of expression fails and the 
hemorrhage is profuse, the cavity of the uterus must be entered 
and the placenta gently separated and removed. 

To perform this operation one hand grasps the fundus 
securely, while the other is inserted into the vagina and fol- 
lows up the cord as a guide till the placenta is reached. A 
detached edge is then felt for, the finger-tips inserted between 
the placenta and the uterine wall, and by gentle lateral move- 
ments of the hand the separation is completed and the 
placenta gently grasped. The outer hand then makes fric- 
tion over the fundus until a contraction has been stimulated, 
when the internal hand and placenta are slowly withdrawn 
(Fig. 100). 

The internal hand and the placenta should never be with- 
drawn until uterine contraction has occurred, on account of 
the danger of producing inversion of the uterus. The hand 
should then be re-introduced and the whole uterine cavity 
explored to make sure that no fragments of placental tissue 
have been retained. A hot intra-uterine douche should then 
be given. It is advisable to administer a full dose of ergot as 
soon as the uterus has been emptied. 

MATERNAL DYSTOCIA. 

The subject of maternal dystocia may be divided into three 
headings : 

1. Anomalies in the forces of labor ; 

2. Anomalies in the pelvis ; 

3. Anomalies in the maternal soft structures. 

1. ANOMALIES IN THE FORCES OF LABOR. 

Precipitate Labor. 

Excessive power in the expulsive forces of labor may result 
in the very speedy completion of the act. 

Etiology : The condition is usually due to undue excitability 
of the sympathetic nervous system, rather than to excessive 



PRECIPITATE LABOR. 269 

muscular development. It may therefore be met with in 
young primij^arse, as well as in women of more advanced age 
and of greater muscular development. The rule is that the 
precipitancy occurs in the second stage of labor, the first stage 
being quite normal. 

Conditions causing relaxation of the pelvic floor, as debili- 
tating diseases, previous laceration, etc., favor the occurrence 
of precipitate labor. 

Powerful emotions, such as fear or anxiety, may act by 
increasing the force of the uterine contractions. 

Sudden and powerful uteynne contraction with the patient in 
the erect posture may result in the rapid expulsion of the 
foetus, which may fall to the floor and receive serious injury. 
Thus it not infrequently happens that women are suddenly 
delivered while sitting in a priv^y or water-closet, and the 
child may fall into the cesspit or bowl of the closet and 
perish before aid is secured. 

Prognosis : Lacerations of the vagina and perineum, hemor- 
rhage from partial or complete separation of the placenta, 
inversion of the uterus, and occasionally retention of the 
placenta, associated with hour-glass contraction of the uterus, 
may be mentioned as sequelae of precipitate labor. 

The sudden evacuation of the uterine contents may lead to 
severe or even fatal syncope on the part of the mother. The 
foetal mortality is somewhat greater than normal. 

Treatment : When the uterine action is powerful and the 
foetus descends rapidly, it may be held hack by inserting the 
fingers in the vagina and resisting the advance of the pre- 
senting part, while at the same time chloroform is administered 
to the mother. The patient should be instructed to keep the 
mouth open, and to pant or cry out during each pain. 

If a previous labor has been precipitate, the woman should 
be kept constantly in bed after the onset of labor. If the 
pains tend to become too powerful, chloral should be freely 
administered. Fifteen or twenty grains may be given at a 
dose, and repeated at intervals of twenty minutes until a 
drachm has been given or the action of the drug has been 
obtained. It is advisable to administer chloroform while 
waiting for the chloral to be absorbed into the system. 

The management of the third stage of labor demands special 



270 PATHOLOGY OF LABOR. 

care, for in these cases there is often a complete absence of 
contraction after delivery of the child ; hence the uterus becomes 
extremely relaxed in the intervals between the pains. The 
fundus should be kept well under control, firm friction made 
between each pain to stimulate contraction, and plenty of time 
should be given before attempting to expel the placenta. 

If, after the expulsion of the placenta the uterus does not 
remain contracted, a hot (120° F.) intra-uterine douche should 
be given, followed by a hypodermic injection of ergot (aseptic) 
m XX. The fundus should be controlled until the uterus 
remains firmly contracted. 

Delayed Labor; Uterine Inertia. 

When the expulsive action of the uterus is unable to over- 
come the normal resistance of the maternal passages, labor is 
delayed and the pains are said to be " weak.'^ 

Causes : The commonest causes of uterine inertia are pre- 
mature rupture of the membranes, rigid os, a distended bladder 
or rectum, and general debility of the patient. Obliquity of the 
uterus ; overdistention, as in multiple pregnancy or hydramnios ; 
degeneration of the uterine muscle-fibres from inflammation 
or too frequent childbearing ; malpresentation ; uterine tumors 
or tumors of neighboring structures ; and low attachments of 
the placenta, may all be mentioned as causes of uterine inertia. 

Diagnosis : Before making a diagnosis of uterine inertia 
care should be taken to ascertain if the bladder and rectum 
have been emptied. By external examination the contraction 
of the uterus may be felt to be weak, for the organ will not 
assume the intense hardness associated with good uterine 
action. By vaginal examination in the first stage the bag of 
waters does not become tense during a pain, or if the mem- 
branes have ruptured the presenting part does not descend. 

Examination should then be made to ascertain that the 
labor is not delayed by some obstruction. 

The prognosis depends on the stage of labor and the cause 
of the inertia. In the first stage there is little danger to 
either mother or child unless the membranes have been long 
ruptured. In the second stage of labor there is danger to 
both mother and child from prolongation of the labor. 



DELAYED LABOR; UTERINE INERTIA. 271 

No hard-and-fast rule as to how long delay might be with- 
out danger can be laid down. When the head is low in the 
pelvis prolonged delay may cause serious injury to the mater- 
nal parts from pressure of the head. The condition of the 
mother and child should be carefully watched. Danger to 
the child is manifested by a slowing of the foetal heart's 
action, while danger to the mother is indicated by local 
oedema and a rising pulse and temperature. It may be said 
that a delay of over six hours in the second stage warrants 
the artificial termination of the labor. 

Treatment : This depends on the stage of labor and the 
cause of the inertia. The first duty is to ascertain the cause 
of the delay, and, if possible, remove it. The bladder 
and rectum should be emptied. The prolongation of the 
first stage of labor may have exhausted the patient, and when 
this is the case no effort should be made to stimulate uterine 
contractions until the patient has been restored by a good 
rest, and, if possible, sleep. This may be accomplished by 
giving her a hypodermic injection of morphine {^ gr.), and 
repeating it in half an hour if necessary. At the same time 
she may be given some hot broth or milk, or some sherry and 
a biscuit, to maintain her strength. 

Chloral is to be preferred to morphine, as it seldom arrests 
the progress of labor. Two drachms of the syrup of chloral 
may be given in a cupful of warm milk, and repeated in 
half an hour if required. On waking, the patient may be 
given some hot broth or egg-nog. If the contractions do not 
then set in w^ith increased power, efforts may be made to 
stimulate the uterus to action. 

Strychnine (gr. ^-^), administered hypodermically, is proba- 
bly the most valuable uterine stimulant. Quinine in large 
doses (gr. xv), repeated in half an hour, acts well in some 
cases ; but the author has failed to find it completely satis- 
factory. 

Ergot is only mentioned to be condemned, for it tends to 
induce tetanic uterine action, and thus interferes with the 
placental circulation. It should never be used until the uterus 
has been emptied. Hot vaginal douches (120° F.), given at 
intervals of half an hour, often prove of great value. 

Alcohol has proved a very satisfactory uterine stimulant in 



272 PATHOLOGY OF LABOR. 

the author's experience ; it is best given in the form of sherry, 
as recommended by Hirst, and should be slowly sipped, the 
patient being informed that it will surely bring back the 
pains and hasten the delivery. 

In ver}^ obstinate cases a sterilized bougie may be inserted 
into the uterus, and the vagina packed lightly with iodoform 
gauze, as for the induction of premature labor. The intro- 
duction into the cervix of a Champetier de Ribes bag or of a 
Barnes bag is a very useful but troublesome method of treat- 
ment. These not only stimulate the uterus to action, but 
dilate the cervix, and thus assist in overcoming the resistance 
offered by the os. 

The bag of icaters should not be ruptured until the os is 
dilated, unless it is evident that there is an excess of liquor 
amnii present, and that this is the probable cause of inefficient 
uterine action. 

When inertia is present in the second stage of labor the 
patient may be allowed to walk about, in the hope that the 
descent of the head under the influence of gravity will set up 
uterine action by reflex stimulation of the pelvic floor. 

Pressure on the fundus with the patient in the dorsal posi- 
tion may prove of value when employed during uterine con- 
tractions. When other measures fail resource must be had 
to the forceps to terminate labor. 

2. ANOMALIES OF THE PELVIS. 

The great majority of anomalies of the pelvis are of the 
nature of contraction. Contractions in the diameters of the 
pelvic brim give rise to the most serious consequences both 
to mother and to child, in proportion to the degree of ob- 
struction offered to the passage of the foetus. 

Frequency: Until recently it was commonly believed that 
abnormal pelves were much more rarely met with in America 
than in Europe ; but the more general j^ractice of pelvimetry 
which has prevailed in obstetric clinics during tlie past decade 
has revealed the fact that in America deformity of the pelvis 
is met with in about the same proportion of women as in 
Europe. 

The records of European clinics show a wide variation in 



ANOMALIES OF THE PELVIS. 273 

the percentages reported, the difference extending from 1.2 
per cent, in Russia, to 24.3 per cent, in Saxony. Von 
Winckel considers that from 10 to 15 per cent, of German 
women have deformed pelves ; but that in only 5 per cent, is 
the obstruction serious enough to be noticed. 

Among American observers/ Flint, in New York, found 
1.42 per cent, of pelvic contraction; Reynolds, in Boston, 
1.13 per cent.; Crossen, in St. Louis, 7 per cent.; Dobbin, 
in Baltimore, 11.45 per cent. ; and Williams, in Baltimore, 
13.1 per cent. Davis, from the records of 1224 patients, 
concludes that 25 per cent, of the women in the United 
States have pelves smaller than the average, while 7 per cent, 
have pelves larger than the average. 

Hirst states that deformed pelves are by no means rare 
among native-born women in the Eastern States. 

Classification : Various classifications of pelvic anomalies 
have been employed in different countries, but the following, 
taken from Jewett's Practice of Obstetrics, will be found suf- 
ficiently comprehensive to meet all requirements : 

I. Pelves normally proportioned but abnormal in size : 

1. Uniformly enlarged (justomajor). 

2. Uniformly contracted (justominor). 

II. Pelves with anomalies of size, shape, inclination, or 

combinations of these : 

1. Those with minor developmental peculiarities : 

(a) Masculine ; 
(6) Shallow; 

(c) Deep ; 

(d) Funnel-shaped. 

2. Anteroposteriorly contracted : 

(a) Flat non-rachitic ; 

(b) Flat rachitic. 

3. Obliquely contracted : 

(a) By imperfect development of one sacral ala 

(Naegele pelvis) ; 

(b) By imperfect or abolished use of one limb ; 

(c) By spinal curvature. 

^ Davis, E. P., American Journal of Obstetrics, Jan., 1900. 
18— Obst. 



274 PATHOLOGY OF LABOR. 

4. Transversely contracted : 

(a) By imperfect development of both sacral alse 

(Robert pelvis) ; 

(b) By kyphosis of the spine. 

5. Compressed pelvis : 

(a) Malacosteon ; 

(6) Psendomalacosteon rachitic. 

6. Spondylolisthetic. 

7. Pelves distorted by injury, tumors, anchylosis of 

joints. 

8. Deformity due to spinal curvature : 

(a) Kyphotic ; 
(6) Scoliotic ; 

(c) Kyphoscoliotic ; 
{d) Lordosis. 

Diagnosis : Theoretically it is the duty of the physician to 
take careful measurement of the pelvis of every woman he is 
called upon to attend in labor ; practically, this is rarely done 
until delay in the progress of labor calls attention to the fact 
that possibly some obstruction exists in the pelvis. 

Deformity of the pelvis is most frequently met with in those 
women who in childhood have suffered from malnutrition, 
rickets, or tuberculosis of the vertebrae or joints of the lower 
limbs, or who early in life have suffered from accident to a 
limb which has resulted in shortening, dislocation, etc. 

Malnutrition and hard work early in life not infrequently 
result in flattening of the pelvic brim. Rickets may lead to 
various serious pelvic deformities. A history of late denti- 
tion, prolonged indigestion, of not walking after the second 
year, would suggest this disease. An examination of such a 
patient might reveal the square head, pigeon-breast, bead- 
ing of the ribs, or bending or twisting of the long bones 
common to this disease. tJsually these patients are of short 
stature. 

Diseases or accidents resulting in deformity of the spine or 
lower limbs when they have occurred early in life result in 
abnormal development of the pelvis. 

Failure of the head to descend into the jyelvis at or before the 
onset of labor, associated with undue prominence of the abdo- 



PELVIMETRY. 



275 



men, si 



ixacii, should always suggest obstruction at the pelvic brim 
when these conditions are found present in a primipara with a 
vertex presentation. 

Pelvimetry. 

Deformities of the pelvis may be detected by external and 
internal palpation ; and by measurements, both external and 
internal, of those diameters of the pelvis which are accessible. 

For taking pehic measurements the examiner's fingers, a 
tape-measure, and a pair of modified calipers, known as a pel- 
vimeter, are usually employed. The pelvimeter devised by 
Baudelocque in 1775 (Fig. 101) is probably the best, though 
many others have since been invented. 



Fig. 101. 




Baudelocque's pelvimeter. 

Methods of Taking Pelvic Measurements. 

External measurements : Tlie clothing of the patient having 
been rolled well out of the way and the lower part of the body 
covered with a sheet, she lies on her back close to the edge of 



276 PATHOLOGY OF LABOR 

the bed, while the physician stands beside her looking toward 
her head. He then takes the pelvimeter and holds a rod in 
each hand, the tip of an index-linger being on each knob, and 
the reading surface of the scale held so as to be easily read. 

The knobs of the pelvimeter are then placed on the anterior 
superior spines of the ilia or on the tense fascia lata just below 
them, as suggested by Winckel. In the normal pelvis this 
measurement should be about 10 J inches (26 cm.) ; the knobs 
of the pelvimeter are then moved along the external edges of 
the iliac crests until the greatest distance is found, the measure- 
ment of which should be about 11 inches (28 cm.). The 
length of these measurements, as well as any important differ- 
ence between them, enables us to draw our conclusions as to 
the development of the innominate bones, and the width of 
the transverse diameter at the inlet. 

The patient is then made to turn on her side, with the 
thighs slightly flexed. The knob of one rod is then placed in 
the depression just below the spine of the last lumbar vertebra 
and firmly held in this position, while the other knob is placed 
on the symphysis pubis at a point about one-eighth of an inch 
below its upper border, and pressed firmly into position. The 
measurement thus obtained should be about 7 J inches (19 
cm.), and is known as the external conjugate, or the diame- 
ter of Baudelocque. To obtain an idea of the true conju- 
gate 3 J inches (9 cm.) should be deducted from the meas- 
urement of the external conjugate, to allow for the thickness 
of bone and soft tissues ; this would give the normal true 
conjugate, 4 inches (10 cm.). 

The oblique diameters of the brim may be measured by placing 
one knob of the pelvimeter in the depression marking the 
posterior superior spine of one side, and the other knob on 
the anterior superior spine of the opposite side. In sym- 
metrical pelves these measurements are usually equal, and 
should be about 9 inches (22.5 cm.). 

The circumference of the pelvis may be measured by placing 
a tape-line around the body, so that it will pass just over the 
symphysis, under the iliac crests, and over the middle of the 
sacrum behind. In a woman of average development and 
with a normal pelvis this measurement should be about 35 J 
inches (90 cm.). 



PELVIMETRY. 277 

The other external measurements of importance are those 
of the outlet of the pelvis. The transverse diameter of the out- 
let is measured by placing the knobs of the pelvimeter on the 
inner sides of the ischial tuberosities. The anteroposterior 
diameter may be measured by placing one knob of the pelvim- 
eter on the under border of the symphysis pubis and the 
other knob on the skin over the lower border of the tip of the 
sacrum. From this 1.3 cm. must be deducted to allow for 
thickness of the bone, etc. This measurement can be better 
obtained by placing the tip of the middle finger of the left 
hand, inserted into the vagina, against the end of the sacrum 
and pressing the edge of the hand against the lower border 
of the symphysis, the point of contact being marked by the 
index-finger of the right hand and the distance measured 
after the left hand has been withdrawn. 

Internal measurements : A good general idea of the capacity 
of the pelvic canal may be obtained from a careful vaginal 
examination. The points of importance in this examination 
are the thickness, height, and inclination of the pubis ; the 
condition of the lateral walls as regards projections, etc. ; the 
condition of the sacrococcygeal joint ; the curve of the sacrum ; 
and the condition of the promontory, if this can be reached. 

The diagonal conjugate — i. e., the measurement from the 
promontory to the subpubic ligament — can usually be ob- 
tained without much difficulty provided the examination is 
made carefully and methodically. 

The patient is put in the lithotomy position with the but- 
tocks projecting over the edge of the bed or table. The 
examiner then introduces the first two fingers of the left hand 
into the vagina and extends them inward and upward until 
the tip of the second finger rests upon the promontory of the 
sacrum (Fig. 102). Care must be taken not to mistake the 
last lumbar vertebra for the first sacral, or vice versa. The 
radial side of the hand is then raised until the impress of 
the subpubic ligament is felt upon it. With a finger-nail of 
the other hand the point of contact is marked, and both hands 
then withdrawn. With a pelvimeter the distance between the 
mark and the tip of the second finger is then measured. This 
is the length of the diagonal conjugate. From this measure- 
ment t inch (1.75 cm.) should be deducted to obtain the true 



278 PATHOLOGY OF LABOR. 

conjugate diameter. This average difference between these 
two diameters depends upon the height of the symphysis (1 J 
inches, 4 cm.), a normal angle between- the axis of the pubis 
and the true conjugate (105 degrees), a normal thickness of the 
symphysis, and a normal lieight of the promontory. 

When the height of the symphysis is greater than 1^ inches 
(4 cm.), about | inch (2 cm.) should be deducted from the 
diagonal conjugate. 

The true conjugate may be measured Avith almost perfect 
accuracy by means of a special pelvimeter invented by Hirst, 

Fig. 102. 




Internal pelvimetry. Measuring the diagonal conjugate with the hands. (Jewett.) 

of Philadelphia. Hirst's measurement is from the promontory 
to a point one-eighth of an inch below the upper, outer border 
of the symphysis pubis. Hirst's pelvimeter consists of a long, 
straight rod, to which is attached a movable bar having a 
slight curve. 

The physician having placed the middle finger of the left 
hand u})on the ])romontory, the tip of the straight end of the 
pelvimeter is pushed into place alongside, where he holds it 
firmly, while an assistant adjusts the tip of the movable bar 
over a point one-eighth of an inch below the outer upper 
border of the symphysis. This bar is then screwed tight, the 
pelvimeter removed, and the distance between the tips meas- 
ured by means of a ta2)e. The thickness of the symphysis 



PELVES ABNORMAL IX SIZE. 279 

pubis is then measured by guiding one tip of the pelvimeter, 
introduced into the vagina, to a point one-eighth of an inch 
from the top ; the outer bar is then adjusted to the same point 
as before and screwed tight, and the distance between the tips 
measured after the pelvimeter has been withdrawn. 

Pelves Normally Proportioned but Abnormal in Size. 

Uniformly Enlarged Pelvis (Justomajor). 

Definition : This form of pelvis preserves all the characters 
of the normal, but all its measurements are increased. It is 
generally to be found in women of great stature, though it is 
met with occasionally in women below the medium height. 

Diagnosis: All the measurements are found to be in excess 
of the normal while preserving their relative proportion. 

Influence on pregnancy and labor: During pregnancy the 
uterus tends to remain longer in the pelvis than in tlie normal 
condition, thus giving rise to disturbances of the bladder and 
of the rectum. For the same reason the pressure-symptoms 
in the latter part of pregnancy are often severe, and may 
render locomotion difficult. 

The condition predisposes to precipitate delivery. The 
imperfect resistance offered to the head in its descent may 
lead to loss of flexion, and thus retard rotation. 

Uniformly Contracted Pelvis (Justominor). 

Definition : In this type of pelvis the form is preserved, but 
its size is diminished. 

Three varieties of the justominor pelvis are usually de- 
scribed : of these, the most common is the juvenile, in which 
the bones are small and slender ; the masculine, in which the 
bones are heavy and thick ; and the dicarf, or pelvis nana, in 
which the bones are thin and fragile, and the cartilaginous 
junctions between the constituents of the ossa innominata are 
retained. 

Occurrence: The uniformly contracted pelvis is usually to 
be found in under-sized women, though it may be met with 
in women of average height, or even in tall women. It is 



280 PATHOLOGY OF LABOR. 

most commonly met with in America in shop- and factory- 
girls. 

Etiology : The causation of the justominor pelvis has not 
been satisfactorily explained. It is generally the result of 
arrested development due to unfavorable hygienic surround- 
ings and bad nutrition in early life. 

Characteristics : The generally contracted pelvis approaches 
the infantile in type (Fig. 103). The alge of the sacrum are 

Fig. 103. 




Generally contracted dwarf pelvis. (After Winckel.) 

narrow, while the sacrum itself is short and has lessened for- 
ward inclination as compared with the normal. The promon- 
tory is high but not prominent. The pubic bones and sym- 
physis have a lessened inclination outAvard. Thus when the 
patient stands erect the inclination of the pelvic entrance to 
the abdominal axis makes a more obtuse angle than would be 
the case in a normal pelvis (Fig. 104). 

Usually the contraction is not very great. The conjugate 
diameter is seldom below 9 cm. (3^ inches). 

Diagnosis : Careful pelvimetry will show that all the meas- 
urements are below normal, with the exception possibly of the 
external conjugate diameter, which is longer than would be 



PELVES ABNORMAL IN SIZE. 281 

expected, on account of the posterior position and lessened 
inclination forward of the sacrum. In this form of contracted 
pelvis the measurement of the pelvic circumference is gener- 
ally far below ih^ normal, 90 cm. (35^ inches). 

Influence of labor: The increased resistance offered to the 
descent of the head results in flexion being more marked than 
it is in the normal pelvis. The head generally enters the brim 
in the oblique diameter. 

In breech cases the child's head must be well flexed, by the 
operator putting his finger in its mouth and drawing down 

Fig. 104. 




^^ 



Diagram showing difference between normal and justominor pelvis on vertical 
mesial section. Black, normal. Red, justominor. 

the chin before an attempt is made to secure engagement in 
the brim. 

Labor is usually prolonged, and the head undergoes much 
moulding, the caput succedaneum being unusually large. 
The suboccipitobregmatic diameter of the head is com- 
pressed and the occipitomental elongated (Fig. 105). 

Treatment : If the head is advancing under the influence 
of uterine action, no interference is called for. The patient's 
strength must be sustained by appropriate nourishment, and 
opium may be used hypodermically to relieve her suflPerings. 
Plenty of time must be allowed to secure good moulding of 
the head. 



282 



PATHOLOGY OF LABOR. 



Fig. 105. 



When labor is delayed and advance of the head ceases, then 
forceps should be tried. The axis-traction forceps should be 

employed. As a rule, when the 
contraction is not over one centi- 
metre the head can be extracted if 
it be fairly soft and has been al- 
lowed to become well moulded. 

If moderate efforts at extraction 
with the forceps fail to bring about 
advance of the head and the child 
is still living, symphysiotomy should 
be performed. 

Version is not to be recommended 
on account of the difficulty in secur- 
ing the proper amount of flexion 
Diagram showing head un- necessarv to permit the engagement 

moulded and moulded by labor (, ,, % ^ . , i • fi i 

in a justominor case. ot the aiter-coming head in the pel- 

Black, unmoulded. • u„* _ 

Red, moulded. VIC brim. 




Pelves with Anomalies of Size, Shape, Inclination; or 
Combinations of These. 



Minor Developmental Peculiarities. 

Masculine pelvis : In this pelvis the bones are heavy and 
strong, and the whole pelvis is masculine in character. 

Labor may be prolonged and difficult on account of delay 
either in the brim or the outlet. Forceps are frequently re- 
quired to accomplish delivery. 

Shallow pelvis : The distance between the brim and the 
outlet is relatively less in this form of pelvis than in the 
normal. As a rule, labor is easy, though occasionally forceps 
are required. 

Deep pelvis : There is an abnormal increase in the distance 
between the inlet and the outlet in this form of pelvis. Pro- 
vided the diameters are normal, labor is not interfered with. 

Funnel-shaped pelvis : In this form of pelvis the sacrum is 
narrow and has little perpendicular curve, and thus the depth 
of the canal is increased (Fig. 106). In this form of pelvis 
the contraction is most marked at the outlet, and may be in 



PELVES WITH ANOMALIES OF SIZE, ETC. 283 

the anteroposterior diameter, or in the lateral, or in both. 
The pelvis thus approaches the masculine in type. 

Influence on Labor : The mechanism of labor is interfered 
with and the head tends to become extended in the cavity of 
the pelvis ; thus backward rotation of the occiput is likely to 
occur. Labor is usually prolonged, the delay occurring when 
the head is at the outlet. There is greater risk of extensive 
rupture of the perineum. The soft parts at the pelvic outlet 
are likely to be injured by undue pressure of the head. 

Fig. 106. 




Funnel-shaped pelvis. (After Winckel.) 

Treatment: In the lesser grades of contraction the woman 
may be delivered spontaneously or by forceps. In the higher 
grades the Csesarean operation may be required. Symphy- 
siotomy may be employed when the contraction in the outlet 
is not marked and efforts at extraction by means of the for- 
ceps fail. 

Flat Pelves. 

Shortening of the conjugate diameter of the brim is the 
main characteristic of flat pelves. 

Simple Flat Pelves; Non-rachitic. 

Schroder states that this variety of deformed pelvis is more 
frequently seen in Europe than all the other forms put 



284 



PATHOLOGY OF LABOR 



together. In America the simple flat, and the generally con- 
tracted, are the two varieties of pelvic deformity most fre- 
quently met with. 

Hirst, in a series of 316 pelves in women of American 
birth, found flattening to exist in 5.6 per cent. Davis, in a 
series of 1224 pelves, found the simple flat in 5.7 per cent. 

Characteristics : The sacrum is small, and pressed down- 
ward and forward between the iliac bones ; as it is not rotated 



Fig. 107. 




Flat non-rachitic pelvis. (After Kleinwachter 



forward on its transverse diameter, the anteroposterior diam- 
eter of the pelvis is therefore contracted throughout its whole 
extent. The transverse diameter remains as great as in the 
normal pelvis (Fig. 107). 

Frequently in flat pelves there is a double promontory, so 
that a line drawn between the second sacral vertebra and the 
symphysis is often as short as, or shorter than, the true con- 
jugate! 



PELVES WITH ANOMALIES OF SIZE, ETC. 285 

The degree of contraction is usually not great, as it is rarely 
below 8 cm. (3|^ inches), and usually not under 9.5 cm. (3} 
inches). 

Etiology : The condition is usually congenital, though hard 
work in youth, too early walking, and excessive standing on 
the feet may be mentioned as causative factors. 

Diagnosis : This pelvis may be found in small or in large 
women. There is usually nothing in the patient's history or 
appearance to suggest the deformity, unless she has had diffi- 
culty in previous labors. By pelvimetry the transverse 
measurements will be found to be normal, while the antero- 
posterior diameter will be diminished. 



The Flat Rachitic Pelvis. 

Characteristics : Eachitis leads to increased condensation in 
the bones ; hence in the flat rachitic pelvis they are heavier, 
thicker, and somewhat smaller than in the normal. The 
sacrum is wider than in the normal pelvis. 

The iliac crests are more or less everted at their anterior 
ends, so that the interspinal diameter is equal to or greater 
than the intercristal. The ilia are flattened, so that the fossae 
are not so distinctly hollowed out nor are the iliac wings as 
expanded as in the normal pelvis. The pelvic brim is kidney- 
shaped, not heart-shaped, as in the normal pelvis. The con- 
jugate is diminished ; and the trans- 
verse diameter relatively or absolutely _ ^^^- 1^^- 
increased. At the outlet the transverse 
diameter may be widened and the 
anteroposterior be either normal or 
increased (Fig. 108). 

The pubic arch is wider than nor- 
mal, and the symphysis is deeper 
and is rotated on its transverse 
diameter, so that its upper border of'^S^/nSS "and'Sf 
converges toward the promontory, flat rachitic pelvis. 

r^^^ .V i .• n,} , • Black, normal. Red, flat. 

Inus the relation ol the true conjugate 

to the diagonal conjugate is not the same as in the normal 

pelvis (Fig. 109). 




286 



PATHOLOGY OF LABOR. 




In the rachitic pelvis the conjugata vera may be diminished 
p, ,Qg to any extent, depending on the 

degree of deformity present. 

Etiology : Rachitis in its early 
stages causes a softening of the 
bones and ligaments. The weight 
of the body tends to push the 
promontory of the sacrum down- 
ward and forward ; this causes a 
rotation of the sacrum on its 
transverse diameter, and tends 
to elevate the lower part of this 
bone and the coccyx upward and 
backward. The strong ligaments 
attached to the lower part of the 
sacrum prevent its movement 
upward and backward, and the 
result is a sharp bending of the 
bone produced in the neighbor- 
hood of the fourth sacral verte- 
bra. 

Besides the weight of the body, the action of the muscles 
attached to the pelvis helps to bring about the deformity. The 
increased separation of the ischial tuberosities is due to the 
action of the abductor and rotator muscles of the thighs. The 
degree of deformity produced by rachitis depends on the date 
of its appearance, its severity, its duration, and the habits of 
the child. 

Diagnosis : The history of the woman, her appearance, and 
the examination and measurements of her pelvis will permit 
the establishment of a diagnosis. 

The rachitic woman is usually under-sized. She may have 
a square-shaped head or deformed thorax (pigeon-breast), bead- 
ing of the ribs, and curved long bones, whicli may be enlarged 
at the ends. When she lies on a flat surface with the limbs 
well extended lordosis is generally present. 

Pelvic measurement will show that the relation of the spines 
and crests of the ilia is altered. The external conjugate and 
the diagonal conjugate diameters will be found diminished. On 
account of the increased depth of the symphysis and the diver- 



Diagram showing difference be- 
tween normal and rachitic pelvis 
on vertical mesial section. 

Black, normal. Red, rachitic. 



PELVES WITH ANOMALIES OF SIZE, ETC. 287 

geDce of its lower margin, | inch (2 cm.) must be deducted 
from the diagonal conjugate, instead of the average f inch 
(1.75 cm.). 

Care must be taken to ascertain if a double promontory is 
present ; and if so, the conjugate should be measured from the 
projection of the sacrum which is nearer the symphysis. 

Mechanism of Labor in Flat Pelves. 

The contracted condition of the conjugate prevents the 
entrance into the pelvic inlet of the presenting part ; hence the 
abdomen is usually more or less pendulous. 

The presenting part, if it is the head, is usually found at the 
onset of labor to be resting in one or other iliac fossa; or it 
may be firmly pressed down upon the brim in a transverse 
position, so that its longest diameter is accommodated to the 
longest diameter of the pelvic inlet. 

Malpresentations are common, and prolapse of the cord and 
of the extremities is not infrequent. 

The first stage of labor is usually prolonged, because of the 
non-descent of the head. The membranes protrude from the 
OS in a cylindrical pouch. Unfortunately the bag of waters 
usually ruptures early ; and in this case dilatation can only be 
effected by a retraction of the cervix over the head. 

In the second stage of labor the descent of the head is 
resisted by the projection of the sacral promontory. Thus the 
occiput is pushed to one side till it comes into contact with the 
lateral brim of the pelvis, the iliopectineal line, where it is 
arrested. The sinciput not being resisted, then descends, and 
thus extension of the head occurs ; this brings the small bi- 
temporal, instead of the larger biparietal, diameter of the head 
into relation with the contracted conjugate. 

The movement " rounding the promontory " then takes 
place. The posterior parietal bone becomes arrested on the 
promontory, so that the head becomes obliquely displaced by 
turning on its anteroposterior diameter. Thus the sagittal 
suture, instead of remaining in the middle of the pelvic inlet, 
approaches the promontory, as the anterior parietal bone slips 
past the upper border of the symphysis and enters the cavity 
of the pelvis. Then the posterior parietal bone slips past the 




288 PATHOLOGY OF LABOR. 

promontory, and the head enters the pelvic cavity in an extended 
position (Fig. 110). 

Once the obstruction at the superior strait is passed, the 
head usually descends with ease and raj)idity, the rest of the 
mechanism going on normally. Occasionally rotation of the 
head fails, and owing to the width of the transverse diameter 
of the pelvis it is expelled from the vulva in its original trans- 
verse or in an oblique position. 

Head-moulding : The caput succedaneum is generally not 
exaggerated. Usually the child's 
Fig. 110. head shows what is known as the 

"promontory mark.'' This may be 
only a red mark on the parietal re- 
gion, between the anterior fontanelle 
and the parietal eminence which was 
in contact with the promontory. Oc- 
Mouiding of head during casionally there may be an actual de- 
passage through flat rachitic p^ession of the parietal bone in this 

region. Sometimes a gutter-like 
groove may be noted in a line running outward and forward 
on the child's skull. Usually the posterior parietal bone is 
depressed below the anterior, which overlaps it at the sagittal 
suture. 

Treatment of Labor in Flat Pelves. 

Care should be taken to keep the membranes intact as long 
as possible, by keeping the patient in bed during the first stage 
of labor, and by warning her against " bearing down " during 
the pains. 

If the conjugate is not greatly diminished, the head will 
usually engage, provided it be given plenty of time to mould. 
To this end the uterine contractions should be controlled by 
means of hypodermic injections of morphine or of Battley's solu- 
tion. The patient's strength should be maintained by the 
administration of nourishing broths, egg-noggs, ect. If the 
child's head be not unduly ossified, this treatment in the large 
proportion of cases will prove successful. 

Should the head not descend, interference should not be 
delayed too long, for there is danger that the pressure of the 
head may result in [necrosis of the cervical tissue over the 



PELVES WITH ANOMALIES OF SIZE^ ETC. 



289 



promontory and of the anterior vaginal wall behind the sym- 
physis. 

Delivery by the employment of axis-traction forceps must 
then be attempted ; for this operation the patient should be 
placed in Walcher^s position. Should the forceps operation 
fail, delivery of a living child can only be effected by recourse 
to symphysiotomy or to Csesarean section. 



Obliquely Contracted Pelves. 

Obliquely contracted pelves result from : 

(a) Imperfect development of one sacral ala ; 

Fig. 111. 




Singly obliquely contracted pelvis. (After Winckel.) 

(6) Imperfect or abolished use of one limb ; or 
(c) Lateral curvature of the spine. 

19— Obst. 



290 PATHOLOGY OF LABOR. 

In these pelves the pelvic inlet has an oval shape, with the 
small point directed to the atrophied side of the pelvis (Fig. 

111). 

The diagnosis is based npon the history of the woman, and 
a careful examination and measurement of her pelvis. 

Influence on labor : The mechanism of the head in passing 
through an obliquely contracted pelvis is the same as in the 
case of a justominor pelvis. The head usually enters the brim 

Fig. 112. 




Transversely contracted pelvis. (After E. Martin.) 

in extreme flexion, with its long diameter in relation to the 
long, oblique diameter of the pelvis. The long, oblique 
diameter is usually that of the diseased side. As the head 
descends rotation may fail and the occiput may turn toward 
the sacrum. 

Treatment: The long diameter of the head should always 
be brought into relationship with the long oblique diameter of 
the pelvis by manual rotation, should Nature have failed to 
accomplish this before the onset of labor. 

Should descent of the head be delayed, the axis-traction 
forceps should be tried. Should these fail, Csesarean section is 
the only operation available. 

Should the condition be diagnosed early in pregnancy, pre- 



PELVES WITH ANOMALIES OF SIZE, ETC. 



291 



mature labor may be induced, provided the deformity of the 
pelvis is not extreme. 

Transversely Contracted Pelves (Fig. 112). 

Transverse contraction of the pelvis results from : 
(a) Imperfect development of both sacral alee (Robert pelvis) ; 
(6) Kyphosis of the spine. 
This is a very rare deformity. 

As delivery ''per vias naturales" is impossible, Csesarean 
section must be employed. 

Compressed Pelves. 

Two varieties of compressed pelves have been described, the 
malacosteon and the pseudomalacosteon. 

Malacosteon. 

Characteristics : The whole pelvis is greatly altered in shape. 
There is a m.arked bending of the iliac wings, the anterior 
superior spines turning inward. The pelvic brim is tri radiate. 



Fig. 113. 



Fig. 114. 





Diagram showing diflFerence be- 
tween normal and malacosteon pel- 
vis on vertical mesial section. 

Black, normal. 

Red, malacosteon. 



Diagram showing outline of brim of normal 
and of malacosteon pelvis. 
Black, normal. 
Red, malacosteon. 



292 PATHOLOGY OF LABOR. 

owing to the promontory and the acetabula being approx- 
imated. The pubic bones are close together and project as a 
beak. The curve of the sacrum is greatly exaggerated and 
the coccyx points upward into the pelvic canal (Figs. 113, 114 
and 115). 

Etiology : The condition is brought about by great softening 
of the bones resulting from osteomalacia (mollities ossium). 
This disease is met with chiefly in Europe, and is characterized 

Fig. 115. 



Malacosteon pelvis, seen from above. (After Winckel.) 

by a removal of the lime salts from the bones. It usually 
develops during the puerperium, but also occurs in pregnancy. 
The deformity results from transmission of the weight of the 
body through the pelvis to the lower limbs. 

Diagnosis : This is based upon the history of the woman 
and an examination of the pelvis. 

Treatment : When the bones are soft delivery may be effected 
by means of forceps ; when the bones are hard and the deform- 
ity permanent, Csesarean section must be performed should the 
pelvic contraction be extreme. 

Pseudomalacosteon (Rachitic). 

This deformity of the pelvis, produced by severe rachitis, 
may closely approximate that produced by osteomalacia. 



PELVES WITH ANOMALIES OF SIZE, ETC. 



293 



While the deformity of the true pelvis is very much as in 
the malacosteon, the iliac wiogs are widely separated as in the 
typical rachitic condition. 

Spondylolisthetic Pelves. 

Definition : The name applied to this variety of pelvic de- 
formity indicates the condition — " spondylolisthesis," a slipping 
down of the v^ertebra, being derived from anovouko^j " ver- 
tebra/' and olLadr^atZy "a slipping down." 

Fig. 116. 




Spondylolisthetic pelvis. (After E. Martin.) 

The deformity is due to a dislocation of the last lumbar 
vertebra in front of the sacrum. The body of the former is 
usually found to have slipped down in front of the first sacral 
vertebra, to which it has become attached by bony union. An 
exaggerated lordosis is produced, so that two or more of the 
lumbar vertebrae descend into the pelvic inlet and obstruct its 
anteroposterior diameter. The sacrum is pushed downward 
and backward, and to compensate this the anterior half of the 



294 PATHOLOGY OF LABOR. 

j)elvi3 is raised, so that the height of the symphysis is increased 
(Fig. 116). 

Tlie pelvic iulet is thus diminished both laterally and antero- 
posteriorly. 

Etiology: Injury, disease, and developmental defects are 
usually mentioned as predisposing causes. 

The diagnosis is somewhat difficult unless the condition is 
well marked. The stature of the woman is diminished, and 
the ribs may come into actual contact with the iliac crests. 
Lordosis is extreme and the shoulders are carried wtII back 
when the patient is erect. The posterior superior iliac spines 
are widely separated. The pelvic inclination is altered, so that 
the vulvar region is carried somewhat forward. 

Literncd examination reveals the projection of the lumbar 
vertebrae. It may be possible to feel the lower end of the 
aorta pulsating. 

Treatment: The deformity is of the nature of a flattening 
of the pelvis, so that the mechanism of labor resembles that 
which occurs in the flat rachitic pelvis. The obstruction to 
labor depends entirely upon the projection of the lumbar ver- 
tebrae. The treatment is conducted on the same lines as in flat 
pelvis. 

Pelves Distorted by Injuries, Tumors, or Disease. 

Luxation of the femur: This condition, which is usually 
congenital, rarely produces such deformity of the pelvis as 
seriously to obstruct labor. 

Tumors : The commonest tumors which occur in connection 
w'ith the pelvis are exostoses of the joints. Fibroma, sarcoma, 
carcinoma, and enchondroma of the pelvic bones may distort 
the pelvis and so lead to obstruction (Fig. 117). 

Treatment: When the growth is not excessive delivery by 
the natural passages may be possible. When such is not the 
case Csesarean section must be performed. Symphysiotomy 
may be employed in suitable cases, when the sacro-iliac joints 
are not involved in the tumor. 

Fractures of the pelvis : Deformity the result of fracture of 
the pelvic bones is rare. 

Separation of the symphysis pubis : This accident may occur 



I 



PELVES WITH ANOMALIES OF SIZE, ETC. 295 

as a result of great force being exerted in the extraction of the 
liead by means of forceps, or after version has been performed. 
Osteomalacia, rachitis, syphilis, and tuberculosis, or any pro- 
found cachexia, may predispose to the occurrence of this acci- 
dent. 

Diagnosis : The patient generally complains of sharp pain at 
the moment of separation of the joint. Tlie condition may be 
recognized by introducing the index-finger into the vagina 
behind the joint and grasping it. between the finger and thumb. 

Fig. 117. 




Malignant growth of posterior wall of pelvis which necessitated Csesarean section 
in a case of Dr. Cameron. 

Treatment : This consists in the application of a firm pelvic 
girdle as recommended for use after the operation of sym- 
physiotomy. 

Anchylosis of pelvic joints : This condition may affect any 
of the pelvic joints. When the symphysis is affected it has 
but little influence on labor. Anchylosis of the sacro-iliac 
joints may result in serious pelvic deformity. Not uncom- 
monly the sacrococcygeal joint is affected, in which case ob- 
struction may occur at the outlet. Fracture of the coccyx is 
the usual result. 



296 



PATHOLOGY OF LABOR. 



Split pelvis : Waut of complete development of the anterior 
wall of the pelvis results in this condition. It does not cause 
any obstruction to labor, but is likely to be associated with 
precipitate delivery. 

Pelvic Deformities Due to Spinal Curvature. 

Kyphosis : The degree of pelvic deformity resulting from 
kyphosis depends on the situation of the hump ; the nearer this 
is to the sacrum the greater is the deformity of the pelvis. 
Generally the kyphosis occurs about the junction of the dorsal 
and lumbar vertebrae. 

Treatment: If the degree of contraction is slight, labor is 
usually easy. There exists an old saying that ^' hunchbacks 



Fig. 118. 




Lordotic pelvis. (After Klein wachter.) 



have easy labors." When delay takes place forceps may be 
required to eflPect delivery. In extreme contraction the 
Caesarean operation is demanded. 

Lordosis is a rare condition, and is usually secondary to spinal 
disease or pelvic deformity. To a certain degree it affords 



ANOMALIES OF UTERINE DEVELOPMENT. 297 

compensation ; but, as a rule, it is not sufficient, and a rota- 
tion of the sacrum occurs, so that the upper end is thrown 
backward and downward (Fig. 118). The pelvic canal tends 
to become funnel-shaped on account of the projection forward 
of the lower part of the sacrum and the partial obliteration of 
the promontory. 

At the inlet the conjugate is increased while the antero- 
posterior diameter is diminished. The diameters at the outlet 
are usually more or less diminished. 

Scoliosis : The effect of scoliosis on the pelvis depends on the 
situation and extent of the spinal curvature. The lower it is 
and the earlier it occurs, the more serious are the effects pro- 
duced in the pelvis. There is usually some degree of oblique 
contraction present in the pelvis of a patient the subject of 
scoliosis. The condition is frequently associated with rachitis. 

The innominate bone, toward which the lumbar vertebrae are 
curved, receives the greater part of the body-weight, and is 
therefore pushed upward, inward, and backward by the extra 
pressure exerted on it by the head of the femur. The acetabu- 
lum on this side is displaced upward and inward toward the 
sacrum. The symphysis is thus pushed toward the opposite 
side. Thus the greatest degree of pelvic contraction is on the 
side of the spinal convexity. 

In labor the largest part of the head generally descends on 
the roomier side of the pelvis, through which it may pass 
when in a state of good flexion. 

In cases in which the pelvic deformity is extreme the Caesa- 
rean operation must be resorted to. 

Kyphoscoliosis : Rachitis may produce both kyphosis and 
scoliosis in the same woman. If the kyphosis is situated high 
up, but little effect may be produced on the pelvis. 

3. ANOMALIES OF THE MATERNAL SOFT STRUCTURES. 

Anomalies of Uterine Development. 

Varieties: Labor may be complicated in many ways in a 
patient who has a double or septate uterus. Malpositions of 
the foetus are common. The unimpregnated half may cause 
obstruction by its bulk, as it usually undergoes considerable 



298 PATHOLOGY OF LABOR. 

increase in size in sympathy with the impregnated half. If 
the placenta is attached to the septum, severe hemorrhage may 
take place owing to imperfect contraction. Rupture of the 
septum or of the uterus may occur. 

The decidual membrane which has formed in the impreg- 
nated half of the uterus may be retained, and, undergoing pro- 
liferation after delivery, may give rise to septic infection. 

In all cases of anomalous development of the uterus labor- 
pains are usually short and inefficient. 

Pregnancy in a rudimentary horn is a '^^t dangerous condi- 
tion, and when diagnosed it should be ated as a case of 
ectopic gestation. 

Treatment : Forceps or version must be resorted to in most 
of these cases in order to effect delivery. The former should 
be chosen in preference to the latter when possible. Caesarean 
section may be necessary. 

Abnormal Conditions of the Cervix. 

Varieties : Atresia, cicatricial conditions, contraction, and 
rigidity of the cervix, may all give rise to more or less ob- 
struction in the first stage of labor. 

Atresia is a very rare condition, and it is very seldom com- 
plete. The situation of the external os may be recognized as 
a dimple. Pressure upon this with a blunt instrument, such 
as the tip of a uterine sound, is usually all that is required to 
perforate it, after which dilatation usually proceeds rapidly. 

Cicatricial contraction of the cervix is usually due to old 
laceration, or it may arise from a repair operation, from cauter- 
ization, or from syphilis or cancer. 

Rigidity of the Cervix. 

Etiology : When not due to organic changes, it is said to be 
functional. Functional rigidity is common in highly sensitive 
young women and in elderly primiparse. It is usually due to 
some imperfection in the nerve-supply of the uterus, and is 
frequently associated with inefficient uterine contractions. 

Treatment : When the rigidity of the cervix is functional in 
origin it may usually be overcome by the employment of nerve 



DISPLACEMENTS OF THE UTERUS. 299 

sedatives and hot douches. Syr. chloral, hydrat., siss, should 
be administered in warm milk. Ten minutes later a hot vag- 
inal douche (115° F.) should be given, at least two quarts of 
water being used. Every succeeding ten minutes a dose of 
chloral and a hot douche should be given in alternation, till 
the patient has received three doses of chloral and three hot 
douches, should the cervix not yield before. In the author's 
experience this plan of treatment has rarely failed. 

In some cases a hypodermic injection of morphine, gr. J, is 
all that is required. Painting the cervix with a 2 per cent, 
solution of cocaine has been highly recommended. Occasion- 
ally a few whiffs of chloroform with each pain act like a charm 
in relieving this condition when it occurs in a highly nervous 
patient. 

When these methods fail, artificial dilatation by means of 
the fingers or by the introduction of a Barnes or Champetier 
de Ribes bag may be necessary. 

In extreme cases it may be necessary to make several small 
incisions, one-quarter to one-half inch deep, in the cervix be- 
fore proceeding to artificial delivery. 

Impaction of the Anterior Lip of the Cervix. 

Occurrence : This condition may occasionally obstruct the 
advance of the head at the outlet. The anterior lip in these 
cases is caught between the head and pubes, and, becoming 
swollen and oedematous, may actually protrude at the vulva. 
After labor it may slough. 

The proper treatment is to attempt to push it up in the 
intervals between the pains. If it be very oedematous, it may 
be necessary first to make a number of small incisions into it 
to permit the escape of serum, when its reduction may be ac- 
complished without difficulty. 

Displacements of the Uterus. 

Anterior displacement of the uterus at the time of labor is 
not infrequent. It is generally due to a lax condition of the 
abdominal walls. 

Treatment consists in the application of a tight abdominal 



300 PATHOLOGY OF LABOR. 

binder, and in keeping the patient on her back in a half-reclin- 
ing posture during labor. 

Lateral displacement to one or other side may take place. 
The pregnant uterus is usually tilted slightly to the right side. 
When the lateral inclination is excessive part of the propulsive 
force of the uterus is lost, on account of the pressure of the 
presenting part against the lateral wall of the pelvis. 

Treatment : Lateral displacement of the uterus may be cor- 
rected by making the patient lie on the side opposite to that to 
which the fundus is directed. 

Retrodisplacement of the gravid uterus has already been re- 
ferred to. Should the case go on to full term the distention of 
the uterus to accommodate the foetus is accomplished by the 
stretching of the anterior wall, while the fundus and the pos- 
terior wall remain within the pelvis. The condition is known 
as " posterior sacculation ^' of the uterus. 

In these cases the cervix is always displaced anteriorly and 
is pressed close to the abdominal wall. 

Treatment: Caesarean section is seldom necessary in these 
cases, as delivery can usually be effected by artificial dilatation 
of the cervical canal and subsequent internal version. 

Prolapse of the pregnant uterus is possible, but these cases 
never go to full term. The prolapse of the uterus at term is 
usually partial, and only the elongated cervix escapes from the 
vulva, the fundus being in its usual position (Fig. 119). In 
labor the cervix may be retracted within the vagina ; or if it 
be rigid it may become oedematous, and by its bulk prevent 
delivery of the child. 

Treatment: When possible the cervix should be pushed into 
the vagina, and retained there till dilatation occurs, when 
forceps may be applied and the child delivered. When the 
cervix is rigid and oedematous it should be freely incised and 
dilated, to permit the application of forceps to the child's 
head. An assistant may counteract the traction of the forceps, 
by pushing up the cervical tissues during the extraction of 
the child. 

Ventrofixation or suspensio uteri may lead to obstruction in 
labor if the fundus has been attached too low down on the an- 
terior wall. If the fundus is so firmly attached to the abdom- 
inal wall that it is prevented from rising, the anterior wall of 



DISPLACEMENTS OF THE UTERUS. 



301 



the uterus remains crowded down over the pelvic inlet, while 
the posterior is distended and greatly thinned. 



Fig. 119. 




Elongated cervix with procidentia during labor. (Barnes.) 



The complications of labor which have been recorded in such 
cases are : inertia uteri, transverse position of the child, dis- 
placements of the head, cervical rigidity, rupture of the uterus, 
and severe hemorrhage during the third stage of labor. 



302 PATHOLOGY OF LABOR. 

Treatment: If the obstruction olFered by the folded and 
thickened anterior uterine wall be so great as completely to cut 
off the pelvic inlet, Csesarean section must be performed. In 
some cases it may be possible to deliver the child by means of 
version, the danger of this operation being rupture of the 
thinned-out posterior wall of the uterus. The writer in one 
case was able to push the anterior wall out of the way suf- 
ficiently to permit the application of the forceps to the head, 
which was then drawn down. 

Abnormal Conditions of the Vagina and Vulva. 

Longitudinal and transverse septa may be present in the 
vagina and obstruct the advance of the presenting part of the 
foetus. They are seldom very dense in structure and are easily 
ruptured. If they do not yield, they may be divided between 
ligatures. 

Unruptured hymen : This condition may be found present in 
labor ; it causes but slight obstruction ; occasionally it may be 
necessary to incise it. 

Atresia of the vagina : Narrowing of the vagina may be 
due to maldevelopment or to cicatricial contractions after pre- 
vious injury. 

Treatment : Hot douches followed by injections of sterilized 
sweet oil may be employed to soften the part. Dilatation may 
be eifected by the use of Champetier de Ribes's bag. 

Rigidity of perineum : The perineum mav be so rigid as to 
prevent advance of the foetus. This condition is common in 
muscular women and in elderly primiparse. 

Treatment : In these cases the forceps may be required to 
draw down the foetus. During delivery the perineum may be 
softened by the free use of hot fomentations, care being taken 
to smear the parts with vaseline, to prevent burning. When 
laceration is certain, episiotomy may be performed. 

Haematoma : This condition is, when present, found at the 
vaginal orifice. 

Treatment: If large enough to obstruct labor, the tumor 
should be excised and the contents cleared out ; after delivery, 
if hemorrhage from the cavity takes place, it should be packed 
with iodoform gauze. 



TUMORS OF THE GENITAL CANAL, ETC. 303 

Varicose veins when present seldom obstruct labor. They 
may rupture or be so bruised as to slough afterward. 

(Edema of the vulva due to heart or kidney disease may ob- 
struct labor. Multiple punctures should only be resorted to in 
extreme cases, as there is great risk of sepsis or gangrene fol- 
lowing delivery. 

Abnormal Conditions of the Bladder. 

Distended bladder : This is a not uncommon cause of delay 
in labor, and should always be borne in mind. The urine 
should be removed with a sterile, long, soft catheter, the pre- 
senting part being pushed up so as to permit access to the 
bladder. In cases in which it is impossible to pass the cathe- 
ter perforation through the abdominal wall may be required. 

Cystocele : In this condition the bladder may protrude 
through the vulva. 

Treatment : The urine must be drawn by means of a soft 
catheter, and the prolapsed part afterward pushed gently up 
above the presenting part of the foetus. If reduction prove 
impossible, the part must be held up while the child is ex- 
tracted by means of the forceps. 

Vesical calculus : If small, the calculus may not obstruct 
labor. If possible, it should be pushed up above the sym- 
physis. 

When large, it may be extracted after dilating the ure- 
thra ; or it may be necessary to incise the bladder through the 
anterior vaginal wall. After labor the incision may be 
sutured. 

Tumors of the Genital Canal and Neighboring Organs. 

Carcinoma of the cervix : It may be said that, as a rule, 
when this condition is present at full term serious obstruction 
to labor results. Spontaneous delivery may occur if the dis- 
ease is limited to the anterior lip and is not surrounded by a 
large area of cicatricial infiltration. 

Hemorrhage and sepsis are likely to arise during the puer- 
perium. 

Csesarean section is the proper treatment, if the disease is 
fairly extensive. 



304 



PATHOLOGY OF LABOR. 



Fibromyomata, 

The obstructions to labor resulting from the presence of fibro- 
myomata depend on the situation of the new growth. If it 
springs from the lower uterine segmen or cervix, it may 
become incarcerated in the pelvis and absolutely prevent the 
descent of the child (Fig. 120). 

Fig. 120. 




/?ec^am 



B/odder 



Per/nei//7i 



Myoma uteri complicating pregnancy. (After Spiegelberg.) 



Effects : They lead to mal presentations and malpositions of 
the foetus, to prola])se of the cord, to adherent placenta, and to 
hemorrhage. The labor-pains are likely to be inefficient. A 
tetanic condition of the uterus is not infrequently met with in 
these cases. 

The pressure of the tumor may produce severe contusions 
or fractures of the foetal skull. The tumor may be so injured 
during labor that sloughing and gangrene may follow and 
give rise to septic infection. 



Ii 



TUMORS OF THE GENITAL CANAL, ETC. 305 

When the tumor is situated on the anterior wall it may be 
displaced upward by uterine contraction, and thus cease to 
obstruct the advance of the child. 

Diagnosis : When situated low down in the uterus a fibroid 
tumor may be mistaken for the foetal head. A careful exami- 
nation should prevent this mistake. 

Prognosis : This depends upon the early recognition of the 
condition and the treatment adopted. The experience of the 
writer leads him to consider the presence of myoma a grave 
complication of labor. In a series of 300 of these cases col- 
lected by Lafleur the mortality for the mothers, of delivery by 
the natural passage, was 25 to 55 per cent, and 77 per cent, 
for the children. 

Treatment : When the tumor or tumors are situated high up 
labor may terminate naturally. In some cases labor is pro- 
longed on account of uterine inertia, and must be terminated 
by version or forceps. 

Wiien the tumor is small and situated low down, it may be 
possible to push it up out of harm's way by placing the patient 
in the knee-chest position. If this fails, it may be possible to 
extract the child by means of the forceps with the woman in 
Walcher's position. If this be impossible, Csesarean section 
must be performed, or else Porro's operation. 

If the tumor is submucous and attached to the cervix, it 
may be possible to remove it by enucleation even after labor 
has begun. After labor the tumor cavity should be packed 
with iodoform gauze. 

In all cases in which delivery takes place through the natu- 
ral passages there is great danger of hemorrhage from imper- 
fect contraction of the placental site. Should hot intra-uterine 
douches and hypodermics of ergot fail to control the hemor- 
rhage, the cavity of the uterus must be packed with sterilized 
iodoform gauze. The gauze may be left in the cavity for three 
or four days, and if necessary it may then be renewed. 

Polypi. 

Mucous polyps usually spring from the cervical canal or 
anterior lip of the cervix, and when present may obstruct 
labor. 

20— Obst. 



306 PATHOLOGY OF LABOR. 

Even if small, these polypi should be removed at the time 
of labor, by transfixing and tying the pedicle, and cutting 
them away. 

Ovarian Cysts. 

These rarely complicate labor. If discovered during preg- 
nancy, they should be removed. Small ovarian tumors may 
prolapse and cause obstruction in the pelvis. 

Treatment : If the tumor be found below the brim at the 
time of labor, efforts should be made to push it up into the 
abdominal cavity. To do this it may be necessary to anaes- 
thetize the patient and to place her in the knee-chest position. 
If it be impossible to reduce the tumor, it may be tapped from 
the vagiua. This operation cannot be recommended, as it 
exposes the patient to the danger of peritonitis, from escape of 
the contents into the peritoneal cavity. It is better to perform 
Caesarean section, and at the same time remove the tumor. If 
the cyst only partially occludes the pelvic inlet, it may be pos- 
sible to effect delivery by version or forceps. 

Vaginal cysts, dermoid cysts, swellings of the tubes and 
broad ligaments, prolapse of a floating kidney to the pelvic 
inlet, hydatid cysts of the pelvis, and tumors of the liver or 
spleen may be found to cause obstruction in labor. 

Rupture of the Uterus. 

Occurrence : Rupture of the uterus may take place during 
pregnancy, labor, or the puerperal period. In the vast major- 
ity of these cases the rupture takes place during the second 
stage of labor, and consists of a laceration of some portion of 
the uterine wall. 

Frequency: This accident is said to occur about once in 
4000 cases, but the writer is of the opinion that it occurs 
much more frequently than is generally thought, as prac- 
titioners are not prone to report these cases when they occur in 
private practice. 

Etiology : The most frequent cause of rupture of the uterus 
is overdistention of the lower uterine segment, the result of 
some obstruction which prevents the descent of the presenting 
part of the child. 



RUPTURE OF THE UTERUS. 307 

Thus pelvic deformity, overgrowth of the child, hydro- 
cephalus, a tumor blocking the pelvis, rigidity of the soft 
parts, or malpresentations, result in contractions of the uterus 
forcing the child's body into the lower uterine segment, which 
becomes enormously distended, while the upper segment, with 
its walls greatly thickened, is drawn up until it forms a dis- 
tinct tumor, w4iich can be felt through the abdominal wall 
above the child. 

There is usually a well-defined line between the thickened 
upper segment and the distended lower segment. This line is 
generally visible, as well as palpable, running obliquely across 
the abdomen somewhat below the umbilicus. This is the 
retraction-ring, or so-called " contraction-ring of Bandl.^' 
When the limit of the capacity of the lower uterine wall in 
stretching and thinning is reached rupture takes place. 

When the uterine wall is iceakened from any cause, such as a 
blow or fall during pregnancy, fatty or other degeneration, or 
from malignant or other disease, rupture may take place early, 
even without much distention of the lower segment. 

Finally, rupture may occur during unskilful attempts at ver- 
sion, the high application of forceps, or separation of an adher- 
ent placenta. 

Rupture of the uterus has been recorded as following the 
administration of ergot to hasten the expulsion of the child. 
Jolly has collected thirty-three such cases. 

Site of the rupture : The tear usually begins in the wall of 
the lower uterine segment and runs transversely. When the 
rupture is spontaneous it usually occurs in the lateral wall. 
When due to traumatism the anterior wall is usually the site 
of the laceration. 

The extent of the tear varies from a small rent limited to the 
muscular coat to complete penetration into the abdominal 
cavity. Usually tlie edges of the wound are jagged and irreg- 
ular, and infiltrated with blood. 

When only the muscular coat is torn, tlie peritoneal covering 
of the uterus may be stripped off for a considerable distance 
beyond the tear, the sac thus formed becoming filled with 
blood-clot. 

The foetus and placenta may escape into the peritoneal cavity 



308 PATHOLOGY OF LABOR. 

when the rent is extensive, and the intestines may prolapse into 
the vagina. 

Symptoms : Rupture of the uterus when extensive is usually 
accompanied with alarming symptoms. The uterine contrac- 
tions have probably been vigorous for some time, and the 
woman's suffering becomes extreme. Complaint is usually 
made of continuous and severe cramp-like pain in the lower 
part of the abdomen. 

On abdominal examination the uterus will be found in a 
state of almost tetanic contraction with the lower segment 
greatly distended. The retraction-ring may be palpable, or 
even visible. Suddenly there is a peculiar sharp, lancinating 
pain, the woman gives a loud cry, and asserts that something 
has torn. The sound of the tear may be audible. Then 
follows absolute cessation of uterine action. Blood flows from 
the vagina, and symptoms of profound shock rapidly develop. 

On making a vaginal examination, the presenting part will be 
found to have receded ; a loop of intestine may be encountered, 
or the hand may pass through the rent into the abdominal 
cavity. 

When the rupture is only partial, there may be no symptoms 
until after the birth of the child. There may be a moderately 
severe hemorrhage before the placenta comes away. Uterine 
action is usually poor, and there may be some difficulty in ex- 
pelling the placenta. The uterus tends to remain flaccid, and 
there may be some post-partum hemorrhage. None of these 
symptoms may suggest the condition actually present. The 
rapid development of septic peritonitis may lead to an intra- 
uterine examination being made within twenty- four or forty- 
eight hours, when a partial laceration will be discovered if 
the uterine cavity be carefully explored. 

The author has had experience of one case in which there 
were no symptoms to indicate that rupture had taken place, 
beyond a somewhat severe hemorrhage with the expulsion of 
the placenta. On the second day of the puerperal period the 
patient developed a slight temperature, and on the third a 
severe hemorrhage took place. On making an intra-uterine 
examination a rent, sufliciently large to admit two fingers was 
found in the posterolateral wall just above the external os. 

The prognosis depends on the site and extent of the lacera- 



RUPTURE OF THE UTERUS. 309 

tion as well as upon the treatment. The maternal mortality 
under the best treatment runs as high as 60 per cent., while 
the mortality of the infants is as high as 90 per cent. 

Complete rupture is much more likely to prove fatal than is 
partial rupture, on account of the involvement of the peritoneal 
cavity. More than one-half of the cases perish within twenty- 
four hours of the accident. The causes of death are sepsis, 
hemorrhage, and shock. 

Treatment : When vigorous uterine contractions fail to cause 
advance of the presenting part, the condition of the lower 
uterine segment should be ascertained. When the retraction- 
ring of Bandl is to be felt half-way between the pubes and the 
umbilicus labor should be terminated as rapidly as possible, in 
order to guard against the occurrence of rupture. The pro- 
cedure to be adopted will depend on the conditions present. 
Before operating the patient should be ansesthetized to the 
surgical degree, and if this fails to relax the uterus completely 
a hypodermic injection of morphine may be given. 

When rupture has taken place the physician^s first duty is to 
empty the uterus and to control hemorrhage. If the child has 
not escaped into the peritoneal cavity, it should be delivered 
rapidly by the application of forceps or by craniotomy. The 
placenta should then be removed manually, and the site and 
extent of the laceration examined. 

In incomplete laceration it is sufficient to irrigate the cavity 
of the rent with a hot antiseptic solution, such as formalin 
(1 : 500), and to pack it gently with iodoform gauze. This 
treatment should be repeated at intervals of from twenty-four 
to forty-eight hours until the rent has healed. 

When the rupture is found to be complete the treatment 
depends on its site and extent. When it is small and situated 
low down, and but little if any foreign matter has escaped into 
the peritoneal cavity, the rent may be irrigated and packed 
with iodoform gauze. In such a case a close watch should be 
kept for symptoms of peritonitis ; and if such develop the abdo- 
men should be promptly opened, the peritoneal cavity cleansed, 
and thorough vaginal and abdominal drainage provided. 

When the rupture is extensive the abdomen should be 
promptly opened and the peritoneum cleansed of all clots and 
other foreign matter. If the edges of the wound are ragged 



310 PATHOLOGY OF LABOR. 

and infiltrated with blood, no sutures will hold ; in this case 
some authors recommend that the uterus be removed, while 
others claim excellent results from merely providing for good 
vaginal and abdominal drainage. 

The condition of shock, if present, should be treated by saline 
injection, strychnine, digitalis, and brandy, and the application 
of heat to the surface of the body. 

In the author's experience, limited to four cases in which 
treatment was possible, most excellent results followed careful 
irrigation and gauze packing. In two of these cases the per- 
forations, though small, extended completely through the 
uterus. The hemorrhage was severe in all four cases, but 
could be fairly well controlled by pressing the uterus firmly 
down into the pelvis from above. 

After the hot douche the blood ceases to flow for a short 
period ; this time must be utilized by quickly packing the 
cavity of the rent with gauze, which may be guided into place 
along the fingers of the left hand placed in the cervix. 

Great care must be exercised in removing the gauze packing, 
when this is necessary ; it must be drawn out bit by bit, slowly 
and gently, in order to avoid starting a hemorrhage. The most 
rigid asepsis is required in the performance of each dressing of 
the laceration. The gauze packing should not be too firm, 
though sufficient should be inserted to prevent bleeding, but 
not so tightly packed as to prevent free drainage. 

Inversion of the Uterus. 

Occurrence : This accident is fortunately extremely rare. It 
is met with more frequently in private than in hospital prac- 
tice. Inversion of the uterus may be acute or chronic. It is 
with the acute form the obstetrician has to deal. The inver- 
sion may be pcuilal or complete. 

In partial inversion the fundus may be the site of a cup- 
shaped depression, or it may actually prolapse sufficiently to 
protrude from the os. 

In complete inversion the uterus is turned inside out, and 
may j)rotrude from the vulva, appearing as a rounded mass 
between the patient's thighs. 

Etiology : Complete inertia uteri, or uterine paralysis, at the 



i 



INVERSION OF THE UTERUS. 311 

close of the second stage of labor, is the most important pre- 
disposing cause. It may occur spontaneously, and immediately 
follow the birth of the child. 

It has been produced by unskilful attempts at placental ex- 
pulsion. Traction on the cord, to aid the expulsion of the pla- 
centa, has brought about inversion. When there is an actual 
or relative shortening of the cord it is possible that the trac- 
tion on the placental site may drag down the fundus so as ulti- 
mately to produce inversion. 

Symptoms : The inversion usually takes place suddenly, and 
is associated with severe shock, pain, and hemorrhage. Vesical 
and rectal tenesmus may be present. The pain is usually severe, 
while the hemorrhage is rarely profuse. By abdominal exam- 
ination the absence of the uterine tumor will be noticed. On 
making an internal examination the inverted fundus will be 
found either protruding from the os or possibly completely fill- 
ins^ the vagina. 

Diagnosis : Inversion of the uterus can usually be diagnosed 
by a careful external and internal examination. The only con- 
dition from which it must be differentiated is prolapse of a 
uterine polypus. The most important point in distinguishing 
between these conditions is the presence or absence of a uterine 
cavity. This can usually be demonstrated or excluded satis- 
factorily by the introduction of a uterine sound. 

Prognosis : In the acute form the mortality-rate is extremely 
high. Death may take place in a few hours from shock, hem- 
orrhage, or exhaustion, or later from septicaemia. 

Recovery has followed spontaneous reposition, and after sep- 
aration of the inverted organ by sloughing. 

Spontaneous reposition is more likely to occur when the 
inversion is partial than when it is complete. 

Treatment : Reposition by taxis is the only treatment usually 
available. If the placenta is still attached to the uterus, it 
should be separated before reposition is attempted. The uterus 
should be douched with a hot antiseptic solution. The patient 
should then be anaesthetized and placed in the lithotomy posi- 
tion. The body of the uterus should be gently pushed back 
within the vulva, and the operator's hand inserted into the 
vagina and well back toward the sacrum, having the palm 
directed upward. The finger-tips then grasp the lower uterine 



312 PATHOLOGY OF THE PUERPERAL PERIOD. 

segmeDt and exert pressure upon it, in a direction upward and 
forward, toward the anterior abdominal wall, and in the axis 
of the pelvic inlet. 

After the reposition has been completed the hand should be 
kept within the cavity until a contraction occurs, when it may 
be gently withdrawn. A hot intravaginal douche should then 
be given, and strychnine (gr. ■^-^) combined with ergotine (gr. 
■Jq) administered hypodermically. 

If efforts at immediate reposition fail, it should be attempted 
again within a few hours. 

If it be impossible to reduce the inversion, measures should 
be taken to prevent the occurrence of septic infection, and the 
case left for operative treatment at a later date. If infection 
occur, the best method is vaginal hysterectomy. 



PATHOLOGY OF THE PUERPERAL PERIOD. 
HEMORRHAGES DURING THE PUERPERIUM. 

Post-partum Hemorrhage. 

Definition : Excessive loss of blood from the genital canal 
immediately following the birth of the placenta, or taking 
place within twenty-four hours of labor, is usually termed post^ 
partum hemorrhage. 

Etiology : The commonest cause of this grave accident is mis- 
management of the third stage of labor. Spiegelberg has 
stated that severe post-partum hemorrhage is almost without 
exception the fault of the medical attendant. It is certain that 
this accident is met with much more frequently in private prac- 
tice than in well -organized maternities, the reason being that in 
these institutions the attendants are individuals of special skill. 

Uterine inertia is a frequent cause of post-partum hemor- 
rhage. The uterus fails to retract properly after the expulsion 
of the placenta; hence the placental sinuses remain patent, and 
blood is poured out into the uterine cavity, where clots form, 
which acting as a foreign body may stimulate contractions. 
These contractions are usually weak and inefficient, while the 
intra-uterine clots are more or less firmly attached to the walls, 



POSTPARTUM HEMORRHAGE. 313 

and hence difficult to dislodge. In the intervals between the 
contractions more blood is poured out, until finally by this proc- 
ess the uterus may become distended to its full capacity. The 
external hemorrhage may be insignificant in amount, though it 
is usually greatly in excess of the normal. 

Other conditions which predispose to hemorrhage are : pre- 
cipitate labor ; overdistention of the uterus, as in hydraranios, 
twin pregnancy, etc. ; a distended bladder or rectum ; the reten- 
tion of small portions of the placenta or membranes ; tumors 
and other new growths in the uterus ; and exhaustion following 
a prolonged and difficult labor. 

Certain constitutional conditions predispose to this accident, 
as nephritis, extreme anaemia, and haemophilia. 

Severe post-partum hemorrhage may result from lacerations 
in the lower part of the birth-canal. Lacerations of the cer- 
vix involving the circular artery, or of the vulva involving 
one of the bulbs of the vestibule, may occasion severe hemor- 
rhage. 

Symptoms : The hemorrhage may occur with or after the ex- 
pulsion of the placenta. It may be an abrupt, sharp hemor- 
rhage, or simply steady dribbling which by its persistence 
results in an extensive loss of blood. The bleeding may be 
external, internal, or both. 

The pidse is the most certain indicator of the severity of the 
hemorrhage. If after delivery the pulse-rate shows a tendency 
to become more rapid, the possibility of hemorrhage must be 
borne in mind. It is a good rule not to leave a patient whose 
pulse-rate is 100 or more to the minute till all possibility of 
the occurrence of hemorrhage has passed. 

In a severe case symptoms indicative of extensive blood-loss 
rapidly develop. The pulse becomes rapid and thready ; res- 
piration is shallow^, rapid, and sighing; the patient becomes 
restless in her movements, tossing herself about and calling for 
air. She may complain of thirst. Her skin becomes cold and 
covered with a clammy sweat. If the liemorrhage continues, 
syncope, convulsions, and death bring the jiainful scene to a close. 

The diagnosis is seldom difficult, though in conditions of 
severe shock occurring immediately after labor all the symp- 
toms of severe hemorrhage may be present, except evident loss 
of blood and a relaxed uterus. 



314 PATHOLOGY OF THE PUERPERAL PERIOD. 

The blandied face, clammy skin, rapid, thready pulse, and 
sighing respiration, all indicate hemorrhage ; though the ex- 
ternal h)ss of blood may have been out of all proportion to the 
symptoms present. On palpation of the abdomen the hard 
globular uterus will be missed from its usual location half-way 
between the umbilicus and symphysis, and the soft, boggy fundus 
may be found reaching almost up to the ensiform cartilage. 

In cases in which the hemorrhage arises from lacerations of 
the lower part of the birth-canal the fundus will be found in 
its usual position, firmly contracted, in spite of the fact that 
blood is escaping from the vulva. An internal examination 
by means of a speculum, if necessary, will reveal the bleeding 
point. 

Prognosis : These cases rarely terminate fatally when skilled 
assistance is at hand. The greater the loss of blood the graver 
is the prognosis. The most unfavorable cases are those in 
which tiie blood lost is thin and watery, and fails to clot 
properly, as this is indicative of a blood dyscrasia. 

Treatment of Post-partum Hemorrhage. 

This accident can usually be prevented by the proper man- 
agement of the third stage of labor. The directions given for 
the management of the third stage of labor constitute an out- 
line of the preventive treatment of post-partum hemorrhage. 

The prompt, energetic treatment of a case of post-partum 
hemorrhage calls for self-control, readiness in resource, and 
presence of mind on the part of the physician. His object is 
to secure good, firm contraction of the uterus. It is well to 
have clearly in mind a routine treatment to secure this object. 

The first things to be done is to stimulate the uterus to action 
by making vigorous friction over the fundus, through the 
abdominal wall. As the organ becomes outlined on contract- 
ing, pressure may be exerted in the manner recommended for 
the expulsion of the placenta. Such compression may lead to 
the expulsion of clots from the genital canal, and further 
hemorrhage may cease. If this fortunate result does not follow, 
the free hand should be inserted into the vagina and passed 
into the uterus, and adherent clots may be loosened and broken 
up by scraping the walls with the finger-tips. The uterus 
should then be rubbed and kneaded between the external and 



POST-PARTUM HEMORRHAGE. 315 

internal hands, so as to stimulate contractions. As soon as 
contraction has been secured the internal hand should be with- 
drawn and an intra-uterine douche of hot sterilized water should 
be giv^en. To be effectual, the water should be between 115° 
and 125° F., and at least a gallon should be employed. A 
fountain-douche should be used, and the nozzle, either of glass 
or metal, should be carried to the fundus. While the douche 
is being given the fundus should be kneaded through the 
abdominal wall. 

If the hemorrhage is not checked by this means, the injec- 
tion should be repeated, after adding to the sterilized water 
enough acetic acid to make a 3 per cent, solution — /. e., four 
ounces to the gallon. If this fails to stop the bleeding, then 
the uterine cavity must be tamponed with strips of iodoform 
gauze. 

The technique of this procedure is very simple. The ante- 
rior lip of the cervix is seized with a tenaculum-forceps and 
drawn down to the vulva. The end of a strip of gauze is then 
seized by means of a pair of uterine dressing-forceps and 
guided to the fundus ; then the whole cavity is firmly packed 
with successive layers. It is not necessary to pack the vagina 
as well, but after removing the tenaculum from the cervix a 
strip of gauze may be placed in the upper part of the vagina 
to keep the cervix in place. The gauze may be left in place 
from twenty-four to forty-eight hours and then gently removed. 
It is seldom necessary to repeat the intra-uterine packing. 

As soon as the uterus has been emptied of clots a hypoder- 
mic of ergot (aseptic, Parke, Davis & Co.), 3ss, should be 
given, and repeated in half an hour if required. If after 
the first hot douche no acetic acid is available, a piece of 
sterilized gauze, or even a clean pocket handkerchief, may be 
saturated with vinegar, carried to the fundus, and there squeezed 
out. The vinegar should be strained through cotton-wool 
before being used for this purpose. 

Having cliecked the hemorrhage, the physician's duty is 
then to combat the evil eflPects of severe loss of blood. 

Treatment of Acute Ancemia. 

The pillows should be removed from beneath the patient^s 
head and the foot of the bed raised on some books or bricks. 



316 PATHOLOGY OF THE PUERPERAL PERIOD, 

Hot-water bottles should be applied to the extremities of the 
patient, and she should be covered with warm blankets. If 
there is a tendency to syncope, a hypodermic injection of 
strychnine nitrate (gr. ^^ and nitroglycerin (gr. yl^) should 
be given. 

As soon as possible a quart of water at 110° F., containing 
two teaspoonfuls of common salt, should be injected into the 
rectum. For this purpose a soft-rubber catheter should be 
attached to the nozzle of a fountain-syringe, so that the injec- 
tion may be carried as far up as possible. 

If the hearths action fails to improve, hypodermic injections 
of ether, strychnin, and nitroglycerin may be employed. 

Nausea and vomiting are frequent in these cases, and there is 
but little absorption from the stomach until these cease. As 
soon as the stomach will retain anything, small quantities of 
hot coffee, hot brandy and water, or warm milk may be given 
and frequently repeated. When reaction has been established 
a hypodermic of morphine (gr. -1^) should be given to quiet the 
patient. 

In desperate cases the saline solution may be sterilized, and 
injected beneath the breasts or directly into the median basilic 
vein : 

To insert the salt solution beneath the breasts a large ex- 
ploring-needle may be used. A glass funnel and a piece of 
rubber tubing complete the apparatus. These should be ster- 
ilized after being fitted together for use. The breasts are then 
washed with soap and hot water, and rubbed with alcohol. 
Having filled the funnel, the physician grasps the breast firmly 
with one hand, lifts it from the chest-wall, and with the other 
hand the needle (with the solution flowing from it) is plunged 
boldly into the loose tissue beneath the breast. Care should 
be taken to prevent the entrance of air. 

Intravenous injection is seldom used on account of the time 
required to perform the operation, and because the methods 
before given answer the purpose just as well. For the method 
of operation the reader is referred to works on surgery. 

Convalescence in these cases is slow and tedious. The 
patient should not be allowed to sit upright for two or three 
weeks. The diet should consist largely of fluids, and iron in 
some form should be administered. 



HEMATOMA. 317 

Puerperal or Secondary Hemorrhage. 

Definition : This term is used to denote hemorrhage from 
the genital canal of a woman occurring at any time after the 
first twenty-four hours to the end of the puerperium. 

Etiology : The most frequent cause of secondary hemorrhage 
during the puerperium is the retention of portions of placenta 
and membranes. Clots in the uterine cavity or the dislodge- 
ment of clots in the placental site, displacements of the uterus, 
relaxation of the uterus, fibroids, polypi, partial rupture, the 
separation of a slough, and overdistention of the bladder or 
rectum may be mentioned as giving rise to puerperal hemor- 
rhage. Sudden emotion or constitutional causes may result in 
hemorrhage during the puerperium. 

Diagnosis : Having the causes in- mind, it is the duty of the 
physician to make a careful external and internal examination 
in all cases of secondary hemorrhage. The diagnosis should 
rarely prove difficult. 

The treatment depends on the cause of the hemorrhage. 
After emptying the bladder the cavity of the uterus should be 
explored. Fragments of placenta and menibranes or clots 
should be removed and a hot intra-uterine douche given. If 
the cause is found to be other than those just mentioned, ap- 
propriate treatment should be inaugurated. 

Hsematoma. 

Definition : In this form of hemorrhage the effusion of blood 
is interstitial. The result of this accident is the formation of 
a tumor varying in size with the degree of the hemorrhage. 
The most frequent situation of ha^matoma is in one or other 
labium, rarely in both. It may occur in any portion of the 
genital canal outside of the uterus. 

Etiology : A varicose and congested condition of the pelvic 
veins predispose to the occurrence of this accident. The de- 
termining cause is usually direct injury of the tissues from 
pressure of the foetal head or from forceps. Forcing or strain- 
ing on the part of the woman may lead to the rupture of an 
engorged vein, and so give rise to the condition. It may occur 
before or after the completion of labor. 



318 PATHOLOGY OF THE PUERPERAL PERIOD. 

Treatment: If possible, the absorption of the effused blood 
should be encouraged. Care should be taken to avoid its 
manipulation in performing the toilet of the vulva. Frequent 
gentle irrigation with warm, mild antiseptic solutions may be 
employed. If absorption is delayed, the tumor should be in- 
cised, the contents turned out, and the cavity packed with 
iodoform gauze. If on incising the tumor a bleeding vessel is 
found, it should be tied before packing the cavity. Frequent 
dressing and rigid asepsis are necessary to prevent the occur- 
rence of infection. 

SUBINVOLUTION. 

Definition: When the process of involution of the puerperal 
uterus is arrested or retarded the organ is said to be in a con- 
dition of subinvolution. 

Etiology. 

Any condition which prevents a rapid diminution in the blood- 
supply of the puerperal uterus may be said to be a cause of 
subinvolution. Any condition which interferes unth contrac- 
tions of the muscular tissues of the puerperal uterus tends to 
give rise to subinvolution. 

The following conditions which tend to interfere with the 
diminution of the blood-supply of the puerperal uterus may be 
mentioned as giving rise to subinvolution : hyperplasia of the 
endometrium, the result of local congestion or of mild septic 
infection ; laceration of the cervix ; small fibroids ; metritis, 
generally septic in origin ; retention of secundines or clots ; 
uterine displacements ; chronic constipation ; and the resump- 
tion of the ordinary duties of life too soon after abortion or 
labor. 

Conditions giving rise to subinvolution by interfering with 
uterine contractions are : the retention of large clots or frag- 
ments of the placenta, or placentae succenturiatse ; displace- 
ment of the uterus from overdistention of the bladder ; large 
intramural fibroids ; and peritoneal adhesions from old or 
recent inflammatory attacks. 

Subinvolution is practically always the result of some local 
disorder. Constitutional disturbances very exceptionally give 
rise to the condition, though in women with general lack of 



TREATMENT OF SUBINVOLUTION. 319 

tone, with flabby muscles and diminished eliminative powers, 
subinvolution may occur without any evidence of a distinct 
local cause. 

Diagnosis of Subinvolution. 

The diagnosis is usually easy. 

By the tenth day of the puerperal period the fundus uteri 
should be on a level with or a little below the brim of the 
pelvis. Later, if the condition is suspected, the depth of the 
uterus may be measured by means of the intra-uterine sound. 

The lochia, instead of becoming pale and puriform, remains 
bloody and its discharge is prolonged. The condition is 
usually associated with constipation and a coated tongue. 

Ahlfeld has drawn attention to the fact that free perspiration 
during the puerperium is usually associated with firm uterine 
contractions ; when perspiration fails to appear he always looks 
for uterine relaxation. 

Treatment of Subinvolution. 

In the earlier period of the puerperium the uterus may be 
stimulated to contraction by gentle friction of the fundus 
through the abdominal wall for ten minutes or so, three or 
four times daily. A pill containing ergotin, gr. j ; quinine, 
gr. j ; and strychnine, gr. ^, may be given three times daily. 

Should this treatment fail to improve matters and there is 
no diminution in the loss of blood, the cavity of the uterus 
should be explored with the finger. If necessary, the curette 
and placental forceps may be used, being followed by a douche 
of hot formalin solution (1 : 500), and the introduction of a 
wick of iodoform gauze to the fundus. The latter acts by 
stimulating the uterus to contraction and by favoring drainage. 
The gauze should be removed at the end of forty-eight hours 
and a hot vaginal douche once or twice daily may be ordered. 
Daily free evacuation of the bowels should be secured. 

If the uterus be displaced, it should be put in proper position 
and retained there by means of a pessary. 

Occasionally the condition of subinvolution is not discovered 
until late in the puerperal period, after the woman has been 
walking about for some time. In such cases the cavity of the 



320 PATHOLOGY OF THE PUERPERAL PERIOD. 

uterus should be painted with ChurchilPs solution of iodine, 
and a vaginal tampon of wool saturated with boroglycerin 
should be inserted two or three times a week. 

ANOMALIES AND DISEASES OF THE NIPPLES AND 
BREASTS. 

Anomalies of the Nipples. 

Supernumerary nipples are of frequent occurrence. 

Defects of the nipples are chiefly important as they may 
interfere with nursing. 

Inversion of the nipple is a very common condition, which 
may be congenital or acquired. This defect may constitute an 
absolute impediment to lactation. 

During the last month of pregnancy attempts should be 
made to draw out the nipples by means of a breast-pump. 
When the nipples are small or imperfectly developed daily 
gentle traction upon them by the nurse or physician may result 
in improvement. If this fails, a nipple-shield must be em- 
ployed to enable the child to nurse. 

Anomalies of the Breasts. 

Absence of mammae : While imperfect development of the 
mammae is common, their complete absence is a very rare con- 
dition. It is usually associated with deformities of the pelvic 
sexual organs. 

Hypertrophy of the mammae : This condition is also rare. 
When present it does not of necessity contraindicate nursing. 

Supernumerary mammae : Supernumerary breasts are to be 
met with comparatively frequently. They occur with no 
regularity of situation ; the most frequent position is below the 
true mammae ; they have been found over the pubes, on the 
buttocks, shoulders, and in the axillae. In most cases no 
hereditary influence can be traced. 

Anomalies in Milk Secretion. 

Deficient Secretion. 
Complete absence of milk-secretion is a rare condition ; but 
deficient milk'Secretion is only too frequently encountered. 



ANOMALIES IN MILK SECRETION. 321 

Etiology : Lack of development of the glandular tissue of the 
breasts is the most common cause of deficient secretion of milk. 
This lack of development may be due to hereditary causes, or 
to continuous pressure from tight clothing ; or it may be 
associated with maldevelopment of the other sexual organs of 
the body. 

The size of the breasts is no indication of their ability to 
furnish milk. This function depends entirely upon the 
amount of glandular tissue present in the breasts. Some 
women with well-developed breasts have but little glandular 
tissue, and therefore make poor nurses; while others with 
apparently but poor development of these organs have a rich 
and abundant supply of milk for their offspring. 

The secretion of milk may be diminished by the occurrence 
of fever, hemorrhages, chronic diarrhoea, and insufficient nour- 
ishment; serious organic diseases also result in diminished 
milk-secretion. Emotions profoundly affect the secretion of 
milk ; prolonged grief is a well-known cause of deficient 
secretion. 

The return of menstruation , w^hile it may affect the quantity 
and quality of the milk secreted, cannot be said invariably to 
produce this result. It may be stated that, as a rule, the re- 
turn of this function has but little influence on milk-secretion. 

Treatment : But little can be suggested in the way of treat- 
ment ; good, plain food and plenty of it ; moderate exercise in 
the open air ; three or four glasses of milk daily between 
meals, and a wineglassful of extract of malt thrice daily, con- 
stitute about all the treatment possible. There is no medicinal 
galactagogue of any value in the experience of the writer. 

Excessive Secretion — Polygalactia. 

In this condition, which is not infrequently met with, the 
secretion of milk is in excess of the demands of the child. 

Treatment: The bowels should be kept relaxed and the 
quantity of fluids imbibed reduced. The breasts may be 
compressed by means of a tightly fitting breast-binder. The 
woman should take plenty of hard exercise daily in the open 
air. If this treatment fails, the excess of milk must be 
pumped out at regular intervals. 

21— Obst. 



322 PATHOLOGY OF THE PUERPERAL PERIOD. 

Galactorrhoea. 

This term is applied to an excessive secretion of milk which 
persists after weaning. The flow of milk is not necessarily 
excited by suckling the child. The milk is thin and watery, 
the quantity being excessive. One or more breasts may be 
affected, and the condition seriously impair the general health. 
The condition may last for years. 

Etiology : Nothing definite is known as to the causation of 
this condition. It has been attributed to a relaxation or paral- 
ysis of the circular muscular fibres surrounding the milk- 
ducts. 

Treatment : These cases frequently offer very stubborn re- 
sistance to all treatment. Firm compression of the breasts by 
means of a breast-binder and the administration of potassium 
iodide (gr. x t. i. d.) and of fl. ext. ergot (TTL x). for a consid- 
erable period constitute the usual treatment. General tonics 
and iron should be administered. 

Engorgement of the Breasts. 

Etiology : Keference has already been made to the fact that 
occasionally with the establishment of lactation the breasts 
may become congested and engorged. This condition of en- 
gorgement may occur at any time throughout the period of 
lactation. Exposure of the breasts to cold air and hypersecre- 
tion of milk are the most common causes of this condition. 

Symptoms: The breasts quite suddenly become engorged 
with milk, to such an extent as to occasion very considerable 
distress to the patient. The pain and tenderness may be the 
occasion of more or less elevation of temperature. 

Treatment. 

To relieve the patient it is necessary to remove the excessive 
amount of milk and to prevent further engorgement of the 
breasts. The breasts may be em])tied by permitting the infant 
to nurse ; by the breast-pump ; and by massage. 

If the child fails to empty the breasts, the milk remaining 
may be drawn off by means of the breast-pump. Probably 



ANOMALIES IN MILK SECRETION. 323 

the most satisfactory breast-pump is that known as the 
" English " pump. That part of the pump which is applied 
to the breasts should be free from jagged, rough edges, other- 
wise these may produce some abrasions. 

Massage of the breasts : When properly performed this is 
a very efficient aid in relieving congestion and engorgement. 
It should never be employed if there is evidence of interstitial 
inflammation of the breasts. 

The patient, being in the dorsal position, is directed to sup- 
port her breast by placing her forearm under it and drawing it 
up. The breast is then anointed, with warm oil, after which 
the operator begins the manipulations by placing his finger- 
tips, separated as widely as possible, at the periphery of the 
breast. A rapid though gentle stroking movement is then 
made toward the nipple, the finger-tips being brought grad- 
ually together so as to meet at the termination of the stroke. 
Each segment of the gland is thus rapidly stroked in succes- 
sion, each movement terminating at the nipple. The pressure 
exerted by the finger-tips should be gradually increased, short 
of producing severe pain. This stroking movement in about 
five minutes usually ceases to cause pain. Then the operator 
supporting the breast in the palm of one hand, Avith the finger- 
tips of the other hand selects a nodule of induration, which he 
strokes toward the nipple, gradually employing deeper and 
firmer pressure. Each nodule of induration is thus treated in 
succession. 

Xodules which this manipulation fails to soften may then 
be compressed by placing the hand flat upon them and exerting 
steady gentle pressure downward against the chest- wall. The 
pressure thus exerted should be greatest at the periphery of the 
gland. After a few moments of steady pressure, gentle rotary 
movements of the hand may be made over the lumps. If pain 
is complained of, the stroking movements should be resumed. 

The breast should then be grasped with both hands so as to 
encircle it completely ; and the whole gland gently raised and 
compressed, while the two index-fingers are quickly stroked 
toward the nipple to favor the escape of milk. These various 
manipulations should be repeated at short intervals until the 
glands have been softened and emptied of their contents, when 
a pressure-bandage should be applied. 



324 PATHOLOGY OF THE PUERPERAL PERIOD. 

The most satisfactory breast-bandage, in the opinion of the 
writer, is the Y-bandage, which was first employed in the 
Boston Lying-in Hospital. This may be made of two pieces 
of soft, unbleached cotton or bird's eye towelling, about thirty- 
six inches long and ten or twelve inches wide. I have used 
ordinary hand towels for this purpose, and find they answer 
admirably. These are folded into strips about three or four 
inches wide ; one of these is folded end to end, and the doubled 
end turned over so as to convert the strip into an L-shape, 
wdien the free ends are separated. The apex of this strip is 
then pinned with three or four safety-pins to one end of the 
other strip, so as to form the Y-bandage. 

The breasts are then dusted with powdered starch or other 
dusting-powder, and the longer arm of the bandage slipped 
under the patient's back at the lower part of the scapular 
region until the apex of the fork is just external to the outer 
edge of the left breast. The patient then lifts her breasts 
upward and toward each other, while the lower arm of the 
fork is drawn tightly across the chest beneath the breasts ; the 
inferior border of this arm should extend at least an inch below 
the lower margins of the breasts. 

The upper arm of the fork is then drawn across the chest 
above the breasts in such a way that its upper border extends 
an inch beyond the upper margins of the breasts. The free 
ends of the two arms of the fork should thus meet at the outer 
margin of the right breast, where they should then be drawn 
tight and securely pinned with safety-pins to the strip which 
has been passed beneath the back. The free end of the back 
strip may then lie over the apices of both breasts. The strip 
passing underneath the breasts is then pinned to the binder to 
keep it from slipping up; shoulder-straps may then be pinned 
to the upper arm of the fork and fastened behind to the back 
stri])s, thus keeping the upper arm of the fork from slipping 
down. The hollow between the breasts may then be filled with 
cotton, and this held in place by two safety-pins joined together 
and pinned to the upper and lower arms of the fork. 

In place of this the Murphy binder may be employed. It is 
made of a strij) of thick gray cotton, forty inches long and ten 
inches wide. In tlie upper border of this strip a narrow notch 
is cut for the neck, and two deep notches for the arms. The 



SORE NIPPLES. 325 

binder Is applied tightly over the breasts and pinned in front. 
AVhen it is desired to make applications to the nipples, two 
circular holes the size of a silver half dollar can be cut in the 
Murphy binder ; the margins of these holes should be button- 
hole stitched. 

In cases in which the engorgement is intense and the breasts 
so sensitive that manipulation is impossible much relief can be 
given by the application of hot compresses. Flannel soaked 
in hot water and carbonate of ammonium (sj to the pint), 
wrung dry, and then applied to the breasts, and repeated at 
intervals of five minutes, soon gives relief and permits the 
application of the breast-binder. 

In these cases a free action of the boicels should be obtained 
by the administration of teaspoonful doses of Rochelle salt in 
warm water, at intervals of fifteen minutes till purgation is 
induced. 

Sore Nipples. 

Etiology and symptoms : The child in nursing may macer- 
ate the superficial epithelium of the nipples. Small superficial 
ulcers may thus be formed at the apices or at the bases of the 
nipples, which are difficult to heal because the child in nursing 
separates their edges. The pain caused by this condition 
varies between simple tenderness at the moment the child 
seizes the nipple, and the acutest agony during the whole act 
of suckling. Erosion of the nipples occurs most frequently 
in primiparae. 

Treatment. 

Prophylactic treatment should be begun toward the end of 
pregnancy, as has been mentioned. Close attention to cleans- 
ing of the nipples and of the child's mouth is of supreme im- 
portance. After nursing, the nipples should be washed with 
boric-acid lotion and carefully dried. At least once a day the 
child's mouth should be swabbed with pledgets of cotton soaked 
in glycerinum boracis. The bismuth paste recommended in the 
section on Management During the Puerperal Period may 
be employed, following the precautionary cleansing after nurs- 
ing. To this ointment it may be well to add balsam of Peru 
(Sss) should there be evidence of abrasion. 



326 PATHOLOGY OF THE PUERPERAL PERIOD. 

Painting the nipples, by means of a camePs-hair brush, with 
the compouud tincture of benzoin, or a 10 grain to the ounce 
solution of silver nitrate, will be found very satisfactory treat- 
ment in more severe cases. Deep fissures are best treated by 
daily touching them carefully with the solid stick of nitrate 
of silver. 

In some cases extreme tenderness of the nipples may be 
complained of, and yet the most careful examination fail to 
reveal any trace of either erosion or fissure. In these cases 
extract of witch-hazel (ext. hamamelidis) will be found very 
useful ; it may be employed pure or diluted with two or three 
parts of boiled water. 

The writer has had very satisfactory results from painting 
the tender nipples with a saturated alcoholic solution of ortho- 
form, at least as far as giving relief from pain while nursing is 
concerned. This should be applied with a camePs-hair brush 
just before each application of the child to the nipple. Cer- 
tain writers claim to have had severe inflammatory reaction 
follow its employment, so that it should always be used with 
caution. 

In all cases in which the nipples are tender a glass and rub- 
ber nipple-shield should be employed while nursing. The shield 
should be kept surgically clean. 

In some cases it may be necessary for the mother not even 
to attempt to nurse the child for twenty-four hours, or even 
longer. In these cases the breasts may be emptied by means 
of massage, the breast-pump not being used unless it prove 
absolutely necessary. 

In very exceptional cases nothing but weaning will result in 
permanently relieving the condition. 

Inflammation of the Breasts — Mastitis. 

Varieties : Three forms of mastitis are usually described : 
the most frequent variety is the parenchymatous, or glandular^ 
in which the acini of the gland are primarily the site of the 
inflammation. In the subcutaneous variety the connective 
tissue immediately beneath the skin is attacked. In the sub- 
glandular or post-mammary form the connective tissue between 
the gland and the chest-\vall is the site of the inflammation. 



INFLAMMATION OF THE BREASTS— MASTITIS. 327 

The inflaramation is but rarely confined to one of these lo- 
calities, so that clinically two or all three may be combined, 
especially in cases which do not receive prompt treatment. 
Usually mastitis begins in the acini of the gland, whence it 
spreads to the connective tissue and approaches the skin sur- 
face. 

Frequency : Mastitis occurs in about 6 per cent, of all nurs- 
ing women, though it is most frequently met with in prim- 
iparse. It may terminate by resolution or by suppuration. 

Etiology: All forms of mastitis are of microbic origin. The 
infection is usually due to the entrance of staphylococci, either 
the aureus or albus, though streptococci or other pus-producing 
organisms may give rise to the condition. 

The infection usually arises in a fissure or abrasion of the 
nipple, and spreads either by means of the lymph-channels into 
the connective tissue ; or directly along the epithelium of a 
dud to an acinus, possibly to several. The inflammation may 
at first be confined to the epithelium, but soon spreads to the 
surrounding connective tissue. Impaired general health and 
local mechanical injuries are important predisposing causes. 

3Iilk stasis \^'as at one time thought to be the cause of mas- 
titis, but pathologists have proved that stasis alone will not 
produce the condition. It is possible that stasis of milk results 
in impairment of the epithelium of the ducts and thus renders 
infection more liable to occur. 

A possible source of infection is the blood. Escherich states 
that staphylococci which have gained access to the blood 
through infection of the genital canal are excreted in the milk. 

Symptoms of Mastitis. 

All forms of mastitis are accompanied by the signs of 
inflammation. 

The onset of the inflammation is generally characterized by 
a distinct chill or by a sense of chilliness. The temperature 
begins to rise and the patient complains of pain and tenderness 
in the affected breast. 

In the parenchymatous form one or more tender nodules will 
be found in tlie affected breast. The skin overlying these nod- 
ules may or may not be reddened. Pressure on these nodules 



328 PATHOLOGY OF THE PUERPERAL PERIOD. 

usually produces a sharp, cutting pain. The temperature may 
rise to 104° F., or even higher. 

In the low interstitial form the pain is not so distinctly local- 
ized and no nodule can be felt in the breast. The temperature 
rises more gradually and chilly sensations are more frequent 
than a distinct rigor. The skin over the affected area quickly 
becomes reddened, and it will be frequently noticed that the 
site of the inflammation corresponds to a fissure in the nipple. 
This form of inflammation is very difficult to abort and usu- 
ally results in abscess formation, though if the breast be opened 
early but very little pus may be found. 

Treatment of Mastitis. 

Abortive : The indications are to secure complete rest for the 
affected gland by (a) absolutely prohibiting nursing from either 
breast; (h) removing by means of massage and the breast- 
pump the contents of the glands, and (c) reducing the local 
blood-supply. 

It is important to decide if possible whether the inflamma- 
tion is of the parenchymatous or of the interstitial form. The 
mode of onset, condition of the nipple, appearance and feel of 
the breast, and the fact that the parenchymatous form occurs 
most frequently, will afford assistance in making a diagnosis. 

If the type of inflammation present is parenchymatous, the 
routine of treatment may be given as follows : the breasts are 
emptied by means of massage and the breast-pump, all manipu- 
lations being as gently carried out as possible. The nipples 
are then cleansed and an antiseptic dressing applied, as pre- 
viously recommended. A tightly fitting Murphy binder is 
then applied so as to secure as firm compression of both breasts 
as is possible, without increasing the pain in the affected parts. 
Then an ice-bag may be placed outside the binder over the 
affected portion of the gland. The ice-bag should be kept 
constantly applied for from twelve to twenty-four hours, the 
length of time being determined by the relief of pain and sub- 
sidence of temperature. 

The lessening of the local blood-supply of the gland may 
be obtained by the derivative action of saline cathartics, which 
should be freely administered as previously recommended. 



INFLAMMATION OF THE BREASTS— MASTITIS. 329 

If after twenty-four hours the temperature has dropped and 
the paiu disappeared, the pressure on the breasts may be re- 
duced by loosening the binder somewhat. The ice-bag may 
then be removed for an hour or two, but should be used inter- 
mittently till all tenderness of the breast disappears and the 
How of milk has been re-established. In rare instances the ice- 
bag is not well borne by the patient, in which case a compress 
wrung out of a solution of lead and opium (1 : 40) should be 
applied over the affected portion of the gland and covered with 
oiled silk or a layer of non-absorbent cotton, over which the 
Murphy binder may be lightly applied. 

The treatment of the interstitial form of mastitis differs 
somewhat from the preceding. In this form massage should 
be avoided, as only tending to aggravate the condition. The 
Murphy binder should be applied so as merely to support the 
breasts, but not to compress them ; otherwise the treatment of 
the two forms is the same. In spite of all treatment a large 
proportion of these cases terminate in abscess formation. 

Mammary Abscess. 

The pus may be located in the gland-substance or in the 
submammary connective tissue. 

Symptoms : It is not always possible to be certain that sup- 
puration has taken place from the symptoms given. Fluctua- 
tion, the most certain sign of abscess formation, is rarely to be 
found until late. 

Severe throbbing or stabbing pain suggests abscess forma- 
tion, especially when accompanied with chilly sensations, a 
higher grade of temperature, and greater rapidity of pulse. 
Usually a bluish discoloration and some oedema of the skin 
mark the locality where the abscess will ^' point," especially in 
the more common parenchymatous form. 

In the interstitial form the pus tends to burrow extensively, 
and no actual abscess may be discernible though the whole 
gland is found to be riddled with pus-tracts. If such a case be 
left too long, the pus will be found " pointing '' in several places. 

Surgical Treatment. 

Preliminary: The patient should always be anaesthetized 
before attempting to open or treat a mammary abscess, unless 



330 PATHOLOGY OF THE PUERPERAL PERIOD. 

it be superficial and about to point. The whole breast should 
be well scrubbed with soap and hot water, followed by solu- 
tions of permanganate of potassium and oxalic acid. 

Incision : By careful palpation the pus collection is located, 
and an incision is then made in the skin over its most depen- 
dent portion in a line radiating from the nipple. Through this 
opening a grooved director is then inserted and passed in all 
directions until pus is encountered, when a pair of artery- 
forceps is introduced and opened so as to dilate the tissues 
sufficiently to permit the introduction of a finger into 
the abscess-cavity. All adjacent cavities should then be 
searched for and freely opened, and all friable tissue broken 
down. Additional openings should be made to secure free 
drainage. The walls of the abscess-cavity should be gently 
scraped with a Volkmann spoon. All the openings should 
then be irrigated freely with an antiseptic solution, such as 
foi'malin, 1 : 500. 

Drainage : Instead of employing rubber tubes for drainage, 
gutta-percha tissue which has been stei'ilized by soaking in 
formalin solution, and then folded in strips about half an inch 
wide and six or eight inches long, will be found much more 
serviceable. Several of these strips sliould be drawn through 
the openings, so as to secure drainage in all directions. An 
antiseptic surgical dressing is then applied, and the breast 
firmly bandaged with a broad roller bandage, so as to secure 
even compression throughout, or a Murphy bandage may be 
applied. 

After twenty-four or thirty- six hours the dressings should be 
removed and the abscess-cavity thoroughly irrigated with boric- 
acid or formalin solution. The gutta-percha tissue drains 
should be reinserted and a fresh dressing applied. As soon as 
the discharge has almost ceased, the gutta-percha tissue drain- 
age may be dispensed with and firm compression of the walls 
of the cavity secured by means of antiseptic compresses placed 
under the bandage or binder. The most equable pressure is 
secured by means of a large bath-sponge which has been boiled 
and then wrung out of 1 : 5000 bichloride solution. This 
should be sli^rhtly hollowed out so as to fit over the breast, to 
which it is directly ap])liod and covered with oiled silk and the 
bandage or binder. This dressing should be removed daily 



ARREST OF LACTATION. 331 

and the sponge cleansed in a solution of 1 : 5000 bichloride. 
The breast should also be washed with the same solution 
before the dressing is reapplied. 

Nursing : The child may be applied to the sound breast to 
keep up the flow of milk, provided the mother's general health 
is such that it is not desirable to discontinue nursing. 

In the interstitial form of abscess but very little pus may 
be found on incising the breast. All nodules should be opened, 
as the pus tends to burrow very extensively in this form, and 
special care should therefore be given to providing for free 
drainage. 

Abscesses of the areola : The glands of ^Montgomery may 
become infected and result in the formation of small superficial 
abscesses in the areola. 

Treatment : Each suppurating gland should be opened, and 
its walls curetted and then swabbed with strong bichloride or 
formalin solution. 

Galactocele : This is a milk tumor which may form as the 
result of occlusion of one of the lactiferous ducts. Beyond 
causing a little pain these milk tumors are of no importance. 

Treatment : Massage may result in causing the milk to flow 
and thus relieve the condition. Earely these tumors persist 
for a long time, and may become so large as to necessitate 
their being tapped and drained. 

Arrest of Lactation. 

Indications: When the child has perished at birth or when 
the constitutional condition of the mother is such as to pre- 
clude the possibility of nursing, it is necessary to prevent the 
activity of the mammary glands. 

Method : Before the first appearance of breast engorgement 
a tightly fitting Murphy hinder should be applied. Free 
purgation should be induced by means of salines when the 
patient's strength will permit. The amount of fluids ingested 
should be restricted, the patient's thirst being relieved by 
rinsing the mouth frequently with weak tea. 

If the engorgement of the breasts tends to become excessive, 



332 PATHOLOGY OF THE PUERPERAL PERIOD. 

the binder may be removed once or twice daily to permit of 
massage or the use of the breast-pump. Tlie breasts may then 
be covered with giycerite of belladonna and the binder or 
bandage reapplied. Usually under this treatment the breasts 
become inactive in less than a week. 

To arrest lactation when the woman has been nursing for 
some time, firm compression of the breasts by means of the 
Y-binder combined with the use of salines will be sufficient. 
The milk usually flows away readily under the compression 
exerted by the Y-binder, and there is no disposition of the 
breasts to become engorged and caked. 

Massage and the use of the pump should be omitted as 
long as the milk flows away freely. In a few days the breasts 
will cease flowing, when a Murphy binder may be applied and 
worn till the breasts become soft. 

After prolonged lactation there is but little difficulty in 
drawing away the milk when the child is weaned gradually. 
Should secretion persist it may be necessary to employ com- 
pression and to give atropine internally. 

INTERCURRENT DISEASES IN THE PUERPERIUM. 

Miscellaneous Diseases. 

Scarlet fever : This is a rare complication of the puerperium. 
It almost always appears within three days of labor; the 
throat complications are slight, the rash appears quickly, is 
rapidly diffiised, and is usually of an intense dark-red color. 
Convalescence is usually tedious. Occasionally the pelvic 
organs are profoundly affected by this disease, and when this 
is the case the prognosis is very grave. 

AYhen the attack is a frank one and the genitalia are not 
much involved the prognosis is not unfavorable, though the 
condition is a grave one. 

Measles : The puerperium is rarely complicated by this dis- 
ease unless the attack has occurred during pregnancy and has 
led to premature expulsion of the ovum. The condition pre- 
disposes to hemorrhage and also to pneumonia. 

Variola : This is a very grave complication of the puer- 
perium. 



MISCELLANEOUS DISEASES. 333 

Rotheln : This disease does not markedly affect the puer- 
periam. In two or three cases which have come under my 
notice the disease w^as very mild in character, thougli in one 
the rash w^as very marked. 

Erysipelas : This disease usually affects the genitals when 
it occurs during the puerperal period. It is seldom mani- 
fested by a cutaneous eruption. When the genitals only 
are affected the prognosis is very grave, and it is impossible 
to distinguish the case from one of ordinary streptococcus 
infection. 

Erythematous rashes : Puerperal erythema is not an infre- 
quent condition. 

In simple cases there is apt to be a moderate elevation of 
temperature, and the lochia may become offensive. There 
may be some uterine or pelvic tenderness. The condition is 
therefore looked upon as a mild septic infection. 

Iodoform when freely used about the genitals may set up 
an extensive erythematous rash ; in this case the temperature 
and pulse remain unaffected unless the skin irritation causes 
the patient much distress. 

Erythema may be mistaken for scarlet fever, and it is not 
infrequently associated with grave septicaemia. 

Diphtheria : This disease may affect the throat or the genitals, 
in the latter case a variety of general sepsis ensues. 

Pneumonia : This disease constitutes a very grave complica- 
tion of the puerperium. It not infrequently occurs secondary 
to septic infection. Its treatment will be discussed in the 
section on puerperal infection. 

Rheumatism ; arthritis : The diagnosis between septic arthri- 
tis and simple acute rheumatism is a matter of great difficulty 
during the puerperium. Simple rheumatism tends to affect 
several joints, while the arthritis is septic in origin and usually 
only one large joint is affected. In the latter case there may 
be little evidence of general septic infection. Simple rheuma- 
tism usually runs its ordinary course and does not affect the 
puerperium, nor is it affected greatly by it. 

The treatment of acute rheumatism is the same as when it 
occurs at any other time. In septic arthritis recovery is the 
rule, but with a greatly damaged joint. Local treatment only 
is of service, general medication being of little use. 



334 PATHOLOGY OF THE PUERPERAL PERIOD. 



Malaria. 

The puerperal state, it is generally admitted, predisposes to 
malarial attacks. Womeu who are subject to malaria usually 
manifest the disease after delivery, probably as a result of the 
traumatism of labor. 

The malarial attack is usually of a mild type, but occasion- 
ally it may be extremely severe. The disease, which usually 
manifests itself about the third day after delivery, predisposes 
to puerperal hemorrhage ; it also modifies milk secretion, espe- 
cially during the exacerbation of fever. It is not generally 
admitted that the germs of disease can be transmitted in the 
milk to the nursing infant. 

Diagnosis : Malaria occurring during the puerperium must 
be differentiated from septic infection or typhoid fever. The 
diagnosis is occasionally a matter of considerable difficulty. 
The fever in malaria is frequently continuous at first, but soon 
becomes remittent in type. 

In doubtful cases the blood shoidd be examined for malarial 
organisms, and WidaFs test for typhoid reaction should be 
applied. A bacteriological examination of the uterine lochia 
should also be made, for it is quite possible that malarial pois- 
oning may be associated with septic infection in some cases. 
With these tests at one's disposal we should not remain long in 
doubt as to the origin of the fever in any given case. 

Treatment: Usually it is necessary to give large doses 
of quinine to control the fever during the puerperium. 
When the daily dose of quinine is 20 grains or under, it is 
seldom necessary to remove the child from the breast; but 
when this dose is exceeded the infant is likely to suffer from 
the effects. 

Puerperal Anaemia. 

After delivery the blood begins to undergo a change in con- 
stitution by which it is converted from the hydrsemia of preg- 
nancy to the normal proportion of its constituent parts in the 
non-(rravid condition. 

This change is usually completed by the end of the second 
week of the puerperal period. 

Many causes may interfere with this process of involution 



DISEASES OF THE URINARY ORGANS. 335 

of the blood, such as sepsis, severe blood-loss at the time of 
labor, or any wasting or depressing disease. In such cases 
the anaemia tends to assume a pernicious form if treatment is 
neglected. 

Careful blood examinations should be made from time to 
time in these cases in order to judge of the effect of treatment. 

The treatment consists in the administration of tonic drugs 
and careful feeding. Iron and arsenic, in the form of the com- 
pound Blaud pill, usually give satisfactory results. In some 
cases in which iron is not well borne arsenic alone will succeed. 

Hemorrhoids. 

Great discomfort is frequently caused by an attack of hem- 
orrhoids during the earlier days of the puerperal period. 

Treatment : The bowels should be freely opened, and great 
relief may be obtained by the application of hot compresses 
wrung out of hot lead-and-opium solution (1 : 40). In some 
cases the application of ice is more comforting to the patient. 
An ointment composed of equal parts of ung. gallse cum opio, 
ung. stramon. and ung. bellad. will further relieve pain. 

Diseases of the Urinary Organs. 

Retention of urine : Patients not infrequently complain of 
inability to urinate after delivery. The condition may be the 
result of injury to the urethra or the anterior vaginal wall 
during labor. Many women are unable to empty the bladder 
while lying in bed. In others the flow of the urine over 
small abrasions of the vulva sets up irritation, Avhich they 
seek to avoid by holding the urine as long as j)Ossible. The 
relaxed condition of the abdominal walls and the consequent 
diminution of intra-abdominal pressure to some extent inter- 
fere with the function of micturition during this period. 

Treatment : The nurse should be instructed to see that the 
patient empties the bladder at least twice daily. For this pur- 
pose, if unable to pass water otherwise, the patient may assume 
a kneeling posture, or may be raised carefully so as to be able 
to sit on the bed-pan. Hot applications may prove of assist- 
ance, as may also the stimulus caused by the sound of running 



336 PATHOLOGY OF THE PUERPERAL PERIOD. 

water. If these means fail, the nurse should be instructed to 
pass the catheter into the bladder, and to observe the strictest 
antiseptic precautions in so doing. 

Incontinence of urine : Tiiis condition may result from over- 
distention of the bladder from retention of urine. This is the 
commonest cause. Other causes of the condition are paresis of 
the sphincter muscle and vesicovaginal or vesico-uteriiie fistula. 

A careful examination will reveal the cause of the condition. 
The treatment must vary with the cauvse of the incontinence. 

Cystitis : This is unfortunately a common complication of 
the puerperal state. It is usually due either to injury from 
overdistention of the bladder or to careless catheterization. 

Symptoms: Frequent micturition, associated with burning 
and tenesmus, is the most usual symptom ; the temperature 
may rise to 102°-103° F., and the pulse become rapid. The 
urine is usually found to contain mucus and pus in varying 
quantities. 

Treatment: Prompt and energetic treatment is usually de- 
manded to prevent the infection spreading to the ureters and 
kidneys. The bladder should be irrigated daily with a warm 
solution of boric acid (gr. xv-^j). The diet should consist of 
milk only, and the following mixture should be ordered : 

^. Sod. bibor., 

Ac. benzoic, aa ^ss ; 

Inf. buchu, ^vj. — M. 

Sig. A tablespoonful in a wineglassful of water three 
times daily. 

If the condition persist after irrigating with boric solution, 
the bladder should be distended with a solution of silver nitrate 
(gr. ss-^j), all of which should be allowed to drain away with 
the exception of about an ounce, which may be left in the 
bladder. 

Pyelonephritis : This condition may follow an infection of 
the bladder by extension of the disease along the ureters, or it 
may result from a general septic infection. 

Diagnosis can usually be made by an examination of the 
urine. 

Treatment: Stimulation, support, the administration of 



DISEASES OF THE NERVOUS SYSTEM. 337 

bland diuretics, and daily irrigation of the bladder constitute 
the treatment of this condition. 

Haematuria : Bloody urine is sometimes seen after labor, and 
may follow severe contusion of the bladder either by the child^s 
head or the forceps. Xot infrequently the condition is due to 
the persistence of vesical hemorrhoids which developed during 
pregnancy. Usually the blood disappears from the urine in a 
few days without treatment. 

Diseases of the Nervous System. 

Neuritis and Myelitis. 

Xeuritis following labor is due either to (a) nerve injury 
the result of pressure by the child's head or by forceps ; or to 
(6) nerve disease the result of septic infection. 

Neuritis due to injury : The injury to the lumbosacral 
plexus may be so slight as to produce nothing but a partial 
loss of power associated with but slight pain or tenderness on 
movement, which subsides without special treatment in a few 
days. In more severe cases the pain may be intense and con- 
stant, while paralysis and atrophy of the aifected muscles may 
follow, being associated with anaesthesia. Pressure on the 
sacral plexus by means of the finger introduced into the rectum 
gives rise to intense pain. 

Neuritis due to septic infection may assume almost any 
type, being multiple, diffused, or isolated, while either motor 
or sensory nerves may be affected. Occasionally in this form 
the median or ulnar nerves may be affected. 

Myelitis is generally the result of septic infection, though 
Hirst mentions having met with a case which proved fatal, and 
in which no septic focus or apoplexy could be discovered at the 
post-mortem. 

Treatment : In the acute stage fixation and extension of the 
part affected will give the greatest relief. Alternate hot and 
cold applications, and the administration of phenacetin or, if 
necessary, opium, will secure further relief from pain. When 
this stage has subsided massage, electricity, and passive move- 
ment, combined with the administration of pot. iod. (gr. x-xv 
t. i. d.), will hasten the restoration of the part to usefulness. 

22— Obst. 



338 PATHOLOGY OF THE PUERPERAL PERIOD. 



Cerebral Hemorrhage and Embolism. 

A woman the condition of whose arteries predisposes her to 
cerebral hemorrhage is much more likely to be stricken with 
this accident during labor than at any other time. Hemiplegia 
is not infrequently found to follow an attack of eclampsia. 

Cerebral embolism when it is not within the puerperium 
generally follows an endocarditis or phlebitis of septic origin. 



Puerperal Insanity. 

Occurrence : Mental derangement manifests itself in connec- 
tion with child bearing most frequently during the puerperal 
period, rarely during lactation, and but exceptionally during 
pregnancy. 

The term puerperal insanity is here used to designate the oc- 
currence of mental derangement at any time between the birth 
of the child and the termination of lactation. The condition 
is most likely to occur in connection with the first confinement, 
though in a small number of cases mental derangement may 
first manifest itself with the second or third parturition. 

Etiology: Predisposing causes: Jn many cases there is 
present a hereditary disposition to mental derangement. A 
woman with an unstable nervous system is manifestly unsuited 
to bear the nervous strain incident to pregnancy, parturition, 
or lactation. Chorea, epilepsy, and hysteria previously exist- 
ing predispose to the development of insanity in connection 
with the puerperal period. Alcoholism and the narcotic habit 
should be mentioned as predisposing causes. 

Exciting causes : Marked anaemia, sepsis, albuminuria, 
eclampsia, great physical or mental exhaustion, and profound 
emotion have been cited as exciting causes of this condition. 
Mental anxiety in connection with domestic Avorry, desertion, 
and illegitimate pregnancy may be mentioned as an exciting 
cause. 

Forms : Two forms of insanity are ordinarily met with, the 
maniacal and the melancholic : the former occurs much more 
frequently during the ])uerperal period ; while the latter is 
generally associated with lactation. 

Puerperal insanity — symptoms : In both forms j^'^'odromal 



DISEASES OF THE NERVOUS SYSTEM, 339 

symptoms usually manifest themselves. These are irritability, 
restlessness, complaints of petty annoyances, and periods of 
depression, alternating with conditions of nervous tension. A 
condition of general ill-health is usually manifested by loss of 
appetite, indigestion, constipation, and flatulence. The patient 
is usually pale, the pulse is irritable and quick, and she is 
inclined to sudden outbreaks of tearfulness. 

The condition may deepen rapidly, and fever develop, and 
delusions and hallucinations become manifest. The language 
becomes obscene, and frequently erotic manifestations become 
evident. The patient becomes uncontrollable, and is violent 
in her actions ; she may attempt to destroy her infant or attack 
her attendants. 

In the melanchoUe form the patient becomes morose, de- 
pressed, and listless; delusions of persecution are of frequent 
occurrence. She accuses her husband of infidelity, or of even 
worse crimes. She hears voices telling her to kill herself, 
which she may attempt to do unless closely watched. 

In some cases the prodromal symptoms may be so slight as 
to escape observation ; or the condition may be regarded as 
one of ordinary neurasthenia, w^hen suddenly the patient may 
attack and destroy her infant or attendant, or may accomplish 
suicide. 

When a woman during the puerperal period manifests ex- 
cessive irritability or unusual loquacity or taciturnity, associated 
with sleeplessness and constipation, a close watch should be 
kept on all her actions, and she should on no account be left 
alone with her infant. 

Diagnosis : Usually this can be made without difficulty. 
The delirium of mania must be distinguished from that of 
fever and that of delirium tremens. 

Prognosis : About two-thirds of all cases recover their reason 
in from two to six months. Of the other third, 10 per cent, 
die of sepsis or exhaustion, and the balance remain perma- 
nently insane. 

Mania is less likely to result in permanent insanity than is 
melancholia ; but it may be said that the patient's life is in 
greater danger from mania than from melancholia. The older 
the patient, the more rapid the pulse, and the more persistent 
the elevation of temperature, the more grave is the prognosis. 



340 PATHOLOGY OF THE PUERPERAL PERIOD, 

When eclampsia bears a causal relation to the condition the 
prognosis is distinctly more favorable, for these patients re- 
cover much quicker than in any other variety. 

Treatment of Puerperal Insanity. 

When possible, patients suffering from this affliction should 
be removed to special institutions for treatment, and the earlier 
this is done the better. When this is impossible the patient 
should be isolated with two or three attendants who are 
strangers to her. She should never be left for one minute 
alone, the windows should be securely fastened, and all un- 
necessary furniture removed from the room. 

When in mania it is necessary to keep the patient in bed, 
this may be done by covering her with a strong sheet fastened 
at the sides and foot of the bed; otherwise instruments of 
restraint should never be employed, but a sufficient number of 
attendants should always be at hand to control the patient 
if this be necessary. 

The treatment otherwise should be largely symptomatic. 
Nutrition should be promoted by every means possible, but 
sedation should be avoided. 

It is always well to begin by securing a free action of the 
bowels. This may be accomplished by the administration of 
a mercurial with a subsequent saline. The regular adminis- 
tration of intestinal antiseptics, as salicylate of sodium or 
naphthaliu (gr. v t. i. d.), is advisable. 

Sleep may be promoted by giving paraldehyde (^j-ij) at 
night. Instead of this, sulfonal or trional in 20 grain doses 
may be employed. 

Hydrotherapy is of advantage both as controlling the tem- 
perature and in securing sleep. 

The diet should consist of milk in generous quantities at 
first ; later, eggs and meat may be added as digestion improves. 
Stimulants should be employed when necessary. Malt ex- 
tracts are valuable adjuvants to the diet. 

Forced feeding by means of the oesophageal tube may be 
required in rare instances, and it may be replaced at intervals 
by nutrient enemata. 

Iron and arsenic should be given regularly in full doses, as 



SUDDEN DEATH IN THE PUERPERIUM. 341 

soon as the condition of the digestive tract permits of their 
employment. 

As soon as possible the patient should be kept constantly in 
the open air during the daytime ; and exercise short of fatigue 
should be encouraged. 

The fact that pelvic conditions have much to do with the 
development of this condition renders it necessary to make a 
careful examination of the state of these organs in all cases. 
All abnormal conditions should be corrected as far as possible. 
In manv cases operative treatment has been followed by bril- 
liant results ; but to accomplish this, such procedure should be 
adopted early in the history of the case. 

Sudden Death in the Puerperium. 

The most common causes of sudden death in the puerperal 
period are pulmonary embolism, entrance of air into the uterine 
siniises, and heart-failure. 

Pulmonary Embolism and Thrombosis. 

Etiology : Some authorities claim that primary and sponta- 
neous coagulation of blood may take place in the pulmonary 
artery. 

The most generally accepted view is that pulmonary em- 
bolism results from the separation of a portion of a thrombus 
which has formed in some peripheral vein. Thrombosis most 
commonly takes place either in an iliac, femoral, or uterine 
vein. 

Symptoms and diagnosis: This accident may occur at any 
time during the earlier weeks of the puerperal period. The 
symptoms usually develop with great suddenness, and their 
severity depends on the size of the embolus. When the ob- 
struction of the pulmonary artery is complete, death may be 
practically instantaneous ; or it may be preceded by precordial 
oppression, great dyspnoea, and cyanosis. Usually the patient 
utters a sharp cry ; the respirations become shallow, gasping, 
and irregular, and in a few seconds cease altogether. In casea 
in which the embolus is small the onset of symptoms is not 
so sudden ; but they are similar, though not so severe. Death 



342 PATHOLOGY OF THE PUERPERAL PERIOD. 

may not take place for several days, and very rarely recovery 
may follow. The symptoms usually follow some sudden 
movement, such as sitting up, laughing, straining at stool, etc. 

The following may be cited as an illustrative case : the 
patient, a multipara, had made a perfect convalescence after an 
uneventful labor, when on the morning of the thirteenth day, 
after being gently moved to a sofa placed alongside of her 
bed, she suddenly gave a gasp, fell back on the pillows, and in 
a moment lost consciousness. Cyanosis rapidly developed, and 
the respirations became labored and ceased inside of five min- 
utes. The pulse at first was rapid and strong, but quickly 
became thready, and ceased shortly after the failure of respira- 
tion. 

At the autopsy there were found in certain of the larger 
veins in connection with the uterovaginal plexus large, well- 
formed thrombi ; a thrombus was found to extend into the 
right internal iliac vein, where it ended abruptly with a trun- 
cated and apparently broken-off end. Both right and left 
pulmonary arteries were found absolutely occluded with firm 
red clot at their very origin. Nothing abnormal was found 
elsewhere in the body. 

Treatment : Usually death takes place before any treatment 
can be inaugurated. In all cases in which there is evidence of 
venous thrombosis prolonged and complete red should be en- 
joined. From an examination of the records of four of these 
cases which caine under the observation of the writer, in none 
of which there existed any evidence of thrombosis before the 
onset of the fatal symptoms, the only abnormal condition com- 
mon to all was a somewhat increased pulse-rate. In all four 
the pulse-rate is never recorded as being below 80, though 
death took place in each between the tenth and the fifteenth 
days of the puerperal period. In view of this fact the writer 
is in the habit of keeping all cases having an unusually high 
pulse- rate as quiet as possible for at least four weeks after the 
birth of the child, or until the pulse-rate becomes normal. 

In 7nild cases in which treatment is possible the indications 
are to keep up the body-temperature by the application of 
heat externally, to stimulate the cardiac and respiratory organs 
by the administration of approjM'iate remedies, and to secure 
the most absolute physical and mental rest for the patient. 



FEVER DURING THE PUEBPERIUM, ETC. 343 

Entrance of Air into the Uterine Sinuses. 

Causation : Tliis is a very rare accident. Air may find 
entraoce into the uterine sinuses in the course of intra-uterine 
manipulations, such as the introduction of the hand, the giving 
of an intra-uterine douche, or by aspiration following a change 
in posture of the patient. 

Symptoms : These are practically the same as in pulmonary 
embolism. 

Treatment : This consists in the hypodermic administration 
of stimulants and the employment of artificial respiration. 
Inhalation of oxygen gas, in order to inflate the lungs and to 
expel the air emboli, has been suggested. 

Fever during the Puerperium due to Other than Septic 

Causes. 

Elevation of temperature may occur in the course of the 
puerperal period quite independently of septic infection^ from 
such causes as exposure to cold, constipation, emotion, or reflex 
irritation of any kind. 

Emotional fever : Profound psychical impressions, such as 
grief, anger, fear, or even excessive joy, may give rise to some 
elevation of temperature, especially ^Yhen experienced during 
the early puerperium. The mechanism of this elevation of 
temperature is not susceptible of explanation in the present 
state of onr knowledge. 

Jn maternity hospitals emotional fever is frequently met Avith 
in cases of illegitimate pregnancy about the tenth day of the 
puerperium, as a result of anxiety on the part of such patients 
in regard to their ability to provide for themselves and their 
children in the immediate future. In emotional fever the 
temperature may rise to 104°-105° F. ; but the cause being 
usually transient the temperature quickly falls to normal. 

Exposure to cold: Elevation of temperature may follow 
exposure of the breasts or abdomen to cold ; too low a tem- 
perature in the lying-in room or insufficient bed-clothing may 
expose the patient to a chill, which is usually followed by some 
elevation of temperature. 

The administration of some warm drink and the application 
of external heat usually cause the fever to disappear promptly. 



344 PATHOLOGY OF THE PUERPERAL PERIOD. 



Constipation : This is a not infrequent cause of elevation of 
temperature during the earlier part of the puerperium. The 
fever is probably clue to the irritation of retained animal 
alkaloids. 

The administration of a dose of castor oil will probably 
result in a drop of the temperature to normal as soon as 
the bowels have been evacuated. 

Fever from reflex irritation : The effect of constipation when 
it occurs in the puerperium is an example of reflex irritation of 
the nervous system producing fever which at other times would 
have no such result. 

Irritation from engorgement of the breasts frequently results 
in elevation of temperature, as has been mentioned elsewhere. 

Several times we have met with cases of fever in which no 
cause could be found to explain the condition until segments 
of a tapeworm or a round worm appeared in the stools. Fol- 
lowing the administration of appropriate remedies the worms 
were expelled and the temperature promptly returned to 
normal. 

Tympanites : Tympanites, or overdistention of the intestines 
with gas, is not infrequently met with in the earlier part of the 
puerperal period. This condition may or may not be attended 
with fever. When this condition is associated with elevation 
of the temperature care must be taken to distinguish it from 
peritonitis. 

Treatment : Turpentine enemata at short intervals, com- 
bined with the internal administration of small doses of calo- 
mel, usually relieve the patient. 

Usually it is necessary to start the treatment with an enema 
of hot soap-water and turpentine (sij to Oj). Then calomel 
(gr. -jlg-) should be given every hour. At the end of six hours 
a dose of Epsom salt (^ss, in tw^o ounces of hot water) may be 
given ; and if this is not effectual in an hour an enema con- 
taining glycerin (,|j), turpentine (3ij), Epsom salt (^ss), and 
water (|iij) should be given. 

The calomel should be kept up for two days, and then 
reduced to two or three doses daily. As these cases are due to 
paralysis of the muscular coats of the intestine, a hypodermic 
of strychnine (gr. -^-q) should be given every four or six hours 
until the condition improves. 



PUERPERAL SEPTIC INFECTION. 345 



Puerperal Septic Infection. 

The general term puerperal septic infection is here employed 
to designate the many and varied diseased conditions resulting 
from infection of the female genital tract during labor and the 
puerperium, by microorganisms. 

Frequency: Previous to the introduction of the antiseptic 
method of conducting labor the mortality-rate from septic 
infection varied between 10 and 15 per cent, in the large 
maternity institutions. As the result of the application of 
rigid antisepsis and asepsis to hospital practice the mortality 
from septic disease has been reduced to a low fraction of 1 per 
cent. 

In private practice the beneficial results of the antiseptic 
method are much less marked than in hospital practice. Epi- 
demics of puerperal infection are now but rarely heard of, but 
the mortality-returns still show a large proportion of deaths 
following parturition. 

That septic conditions frequently complicate the puf.Tperium 
is evidenced by the overcrowded condition of the gynaeco- 
logical clinics in all parts of the country. A very large pro- 
portion of these gynaecological cases present conditions which 
owe their origin to febrile affections arising during the puer- 
peral period. 

Bacteriology. 

The streptococcus is the microorganism most frequently 
associated with the occurrence of puerperal sepsis. It is to be 
found in nearly all fatal cases. 

The staphylococcus aureus is the next most frequent cause 
of puerperal septic infection. Not infrequently mixed infec- 
tions with streptococci and staphylococci are encountered. 

The gonococcus, bacillus coli communis, bacillus diphtheriae, 
bacillus aerogenes capsulatus, pneumococcus, and bacillus 
typhosus may be mentioned as rare causes of puerperal septic 
infection. These may be found pure or mixed with strepto- 
cocci ; when the latter is the case the infection is generally 
exceptionally virulent. 

The gonococcus plavs an important part in the production 
of puerperal sepsis. Kronig has found it to be present in 50 



346 PATHOLOGY OF THE PUERPERAL PERIOD. 

out o£ 179 cases presenting febrile puerperia. It appears usu- 
ally to cause a mild infection, unless associated with a strepto- 
coccus, in which case the infection is usually very virulent. 

Sapraemia : There is a considerable class of cases in which 
the symptoms are due to the absorption of toxic products pro- 
duced by organisms within the genital tract which do not 
make their way into the blood-current. These are mostly of 
an anaerobic nature, belonging to the putrefactive class of 
microorganisms, of which little is know^n. They usually pro- 
duce gas, and hence give rise to frothy, foul-smelling dis- 
charges. 

Recently a great deal of bacteriological worlv has been carried 
out in the study of the vaginal secretion. It has been prac- 
tically proved that the normal vagina in pregnancy is free 
from pathogenic microorganisms, at least in its upper third. 
The vaginal secretions are commonly strongly acid in their 
reaction, due to the presence of a so-called vaginal bacillus, 
which in its life-processes produces lactic acid. It is probably 
this acid condition of the vaginal secretions, associated with a 
certain leukocytosis due to chemotaxic action, which results in 
the rapid destruction of the pathogenic bacteria should they 
find entrance to the vagina. 

. It has been proved that pathogenic bacteria introduced into 
a normal vagina perish in from eleven to twenty hours through 
the germicidal action of the normal secretions. Preliminary 
antiseptic vaginal douches have been proved to inhibit the 
germicidal action of normal vaginal secretions. Pathogenic 
bacteria have been found to flourish from eight to sixteen 
hours longer in the healthy vagina after antiseptic douching 
than when no douching was employed. 

The cervix has been usually found to contain in its lower 
part a few pathogenic bacteria of greatly diminished virulence. 
Its upper part is invariably sterile in the normal condition. 
The uterine cavity normally is entirely free from microorgan- 
isms, both in the pregnant and in the non-pregnant condition. 

The microorganisms to be found in the lower part of the 
vagina are usually non-infectious ; but should j)athogenic bac- 
teria be present, their virulence is invariably greatly dimin- 
ished as a result of the germicidal action of the normal secre- 
tions. 



PUERPERAL SEPTIC INFECTION. 347 



Pathology of Puerperal Septic Infection. 

The consequences of infection of the genital tract of the 
puerperal woman by microorganisms are extremely variable. 
The infection may be limited to lesions of the vnlva or vaginal 
outlet, or may rapidly spread from this locality to the uterine 
cavity. In the most virulent cases no lesion may mark the 
locality in which the germs have effected an entrance, and yet 
the patient may succumb with extreme rapidity. 

It is the endometrium which is atfected in the majority of 
cases of puerperal septic infection. This endometritis may be 
septic or pxdrid, according as it is the result of infection by 
pyogenic or putrefactive microorganisms. 

* The mildest form of puerperal septic infection is the puer- 
peral ulcer. These puerperal ulcers are simply infected lacera- 
tions of the vaginal outlet and vulva. They usually present a 
dirty, greenish-yellow appearance and are bathed in a purulent 
secretion. Formerly these were termed diphtheritic ulcers, but 
it is very rare that they result from infection with the Klebs- 
Loflfler bacillus. 

Usually they cause but little symptomatic disturbance, and 
therefore their presence may pass unnoticed. 

True puerperal vaginitis may occur, but is rare ; it is char- 
acterized by an inflammation of the vaginal mucosa, which 
swells and softens, becoming bathed in a purulent secretion. 
Lacerations in the vagina when infection occurs usually become 
covered with a pseudodiphtheritic membrane. Karely, true 
diphtheritic vaginitis may occur. 

Endometritis : After labor the more or less lacerated condi- 
tion of the endometrium, and the uneven placental site with 
its thrombosed sinuses, render the uterine cavity specially sus- 
ceptible to the reception and propagation of infective organisms. 
Hence the most common lesion associated witli puerperal septic 
infection is endometritis. 

The infection may be limited to the placental site ; or may 
extend over the whole of the endometrium. 

When the infection is limited to the j^^Ictcentcd site the organ- 
isms develop in the thrombi in the placental sinuses, setting up 
a phlebitis which may be limited to the uterine wall, or may 



348 PATHOLOGY OF THE PUERPERAL PERIOD. 



extend to the suiTouiidin<»: vein 
secondary infection elsewliere. 



and thns 



to 



When the lohole endometrium is involved the mucosa is con- 
verted into a stinldng, necrotic layer, which is bathed in a 
bloody discharge. The quantity of necrotic material formed 
is often considerable, and it recurs with great rapidity after its 
removal by the curette. It consists of necrotic decidual debris 

Fig. 121. 




uterus from patient dying on the tenth day from a pure streptococcus infection. 

and fibrin-exudate loaded with microorganisms (Figs. 121 
and 122). 

Wlien the infection is due to the streptococcus or to the 
staphylococcus the odor of tlie lochia may not be aifected. 
Thus in the most virulent cases the lochia may remain sweet 
throughout ; but when the colon bacillus or any of the putre- 



PUERPERAL SEPTIC INFECTION. 



;49 



facfive germs are present the discharges become foul in the 
extreme. 

In a large number of oases Nature succeeds in limiting the 
infective process to the endometrium, which it does by forming 

Fig. 122. 




Uterus from patient dying on the tenth day from a mixed infection— streptococcus 
and colon bacilli. 



a barrier or obstruction immediately below the necrotic layer. 
This barrier consists of a layer of small-cell infiltration, desig- 
nated the zone of reaction. Beneath this zone the tissues are 
usually quite normal. 



350 PATHOLOGY OF THE PUERPERAL PERIOD. 

Thus on section we find an internal layer consisting of 
necrotic deoidua and fibrin-exudate swarming with micro- 
organisms; below this is a layer, of small-cell infiltration, the 
" zone of reaction/' containing few if any bacteria, while under 
this is the normal uterine tissue. 

Such is the condition found when the infection is due to 
putrefactive microorganisms, as in putrid eiidomefr'dis, so-called 
by Bumm and Doderlein ; or when, if due to pyogenic bacteria, 
these are possessed of but little virulence. 

In the so-called septic endometritis (Bumm and Doderlein), 
when the infective organisms are virulent streptococci or 
staphylococci, the zone of small-cell infiltration may be but 
imperfectly formed, or even entirely absent; while the super- 
ficial necrotic layer may be lacking, or if present be very thin. 
In this case the extension of the infective process occurs by 
means of the lymphatics, and soon spreads through the uterine 
wall to the peritoneal layer, thus setting up a metritis, lym- 
phangitis, and finally a septic peritonitis. This lymphangitis 
usually results in the formation of numerous small abscesses 
throughout the uterine wall, though usually most marked just 
beneath the peritoneum. 

Parametritis : This inflammation of the connective tissue 
contiguous to the uterus frequently follows intra-uterine infec- 
tion during the puerperium. The extension of the microorgan- 
isms usually proceeds along the lymphatics from the endomet- 
rium to the peri-uterine connective tissue. Occasionally the 
infection may originate in laceration of the cervix. 

The infective inflammation of the peri-uterine connective 
tissue produces extensive oedema. This may result in resolu- 
tion, or in suppuration and abscess-formation. When ex- 
tension of the infection occurs along the lymphatics in the 
anterior portion of the pelvis, the inflammatory oedema sur- 
rounds the greater vessels of the thigh in the neighborhood of 
the inguinal region, giving rise to one form oi jMegmasia alba 
dolens. 

Salpingitis : The Fallopian tubes in a certain number of 
cases become infected by direct extension of the inflammation 
from the uterine cavity. Occasionally the infection may be 
carried to the tubes as well as ovaries, by means of the lym- 
phatics. 



PUERPERAL SEPTIC INFECTION. 351 

Peritonitis : This condition usually arises as the result of the 
rapid extension of infection from the uterine cavity by means 
of the lymphatics as already described. 

Peritonitis may rarely occur in consequence of the rupture 
of a pus-tube, or of an ovarian or parametritic abscess. Septic 
peritonitis is usually the direct cause of death in the vast ma- 
jority of fatal cases. 

Pyaemia : As already mentioned, the infective microorgan- 
isms may penetrate the thrombi at the placental site. This 
results in a condition of septic phlebitis, which may be limited 
to the veins in the uterine wall or may extend to the veins in 
the neighborhood. The thrombosis may extend as far as the 
inferior vena cava. These infected thrombi may break down, 
and small portions may be swept by the blood-current to dis- 
tant parts of the body, thus setting up a condition of pyaemia. 

These infected emboli may be deposited in the abdominal vis- 
cera, the lungs, the brain, spinal cord, the joints, or in the sub- 
cutaneous tissue at any portion of the body surface, where they 
give rise to abscesses. In these cases there is very little 
involvement of the uterus, infection then being limited 
usually to the placental site. Death in these cases is usually 
due to exhaustion folloAving a long suppurative process. 

Phlegmasia alba dolens : This condition is known to the 
laity as " milk leg/' as* it was popularly supposed at one time 
to be due to a metastasis of milk. It occurs as the result 
either of the extension of a thrombosis from the uterine veins 
to those of the lower extremities, or of a septic parametritis 
spreading to the connective tissue of the thigh. 

In thrombotic phlegmasia the swelling of the affected limb 
usually begins about the foot, and rapidly extends to the thigh. 

In celhditic phlegmasia the swelling begins in the thigh and 
spreads down the limb. 

In both forms the affected limb becomes enormously swol- 
len. In the first form there is usually more or less tenderness 
along the course of the femoral vein, which is usually marked 
by a line of inflammatory redness. 

Modes of infection: The most common mode of infection is 
the introduction of septic material into the genital canal, on 
the hands or instruments of the physician or midwife ; con- 
tact vdth secretion from tcounds of anv kind, such as infected 



352 PATHOLOGY OF THE PUERPERAL PERIOD. 

abrasions on the hands of a nurse or physician. Air-infedion 
may account for a very small proportion of cases. 

The water used to douche the patient after labor may carry 
pathogenic germs into the genital canal. Contact of the vulva 
with dirty bed-clothes or personal linen, or with infected vulvar 
pads, may account for some cases. 

In one case in the author's experience infection was probably 
due to the dirty hand of the patient, who could not be restrained 
from scratching the vulva. 

As has been shown, the normal vagina is practically sterile, 
so that when infection occurs it is generally the result of the 
introduction of pathogenic material from without. Epidemics 
of septic infection have been stamped out in maternities by 
avoiding all internal examinations. The best morbidity and 
mortality records have been obtained in institutions where 
vaginal examinations have been eliminated as far as possible. 

Auto-infection may he held to account for a very small pro- 
portion of cases of puerperal sepsis. In these cases the patho- 
genic germs are held to be resident in the body, and not to 
have been introduced from without, during or after labor. 
The microorganisms may be lodged in the vagina, cervix, or 
urethra, as in cases of gonorrhoea. Endometritis antedating 
conception may account for the lodgement of germs in the 
uterine mucous membrane, which in the favorable conditions 
existing after delivery may become virulent and set up septic 
infection. In the same way an old pus-sac in one of the 
tubes may rupture during labor and cause a septic peritonitis. 

Symptomatology. 

The symptoms of septic infection may develop within the 
first twenty -four hours after delivery ; but, as a rule, nothing 
out of the ordinary is to be noted until the third or fourth day. 

The onset of infection may be attended with a sense of 
malaise and possibly a slight headache. As the temperature 
begins to rise the patient develops a more or less severe chill, 
which may amount to an actual rigor. The temperature 
quickly rises to 103° F. or higher, and the pulse becomes 
very rapid. Usually there is only one chill, but the tempera- 
ture remains persistently elevated. 



PUERPERAL SEPTIC INFECTION. 353 

The lochia may become scant, but as a rule the discharge in- 
creases in amount. It may remain bloody or may rapidly be- 
come purulent. In the most virulent cases and in those due 
to pure streptococcus infection, very little, if any, odor is to be 
noticed. 

Profuse foul-smelling lochial discharge indicates a putrid 
endometritis ; or a mixed infection due to pyogenic as well as 
putrefactive organisms. 

\Yith the onset of endometritis either of the septic or the 
putrid form, involution of the uterus at once ceases, thus favor- 
ing the spread of the infection, in that the lymph-channels, 
being free from compression, remain patent and thus offer less 
resistance to the passage of microorganisms. 

If the infective process extends beyond the uterus, the 
symptoms which then develop depend upon the tissues in- 
volved. Symptoms indicative of peritonitis, parametritis, or 
pyaemia may thus ensue. 

Peritonitis : The onset of this complication is indicated by 
the occurrence of intense pain, which is at first limited to the 
lower zone of the abdomen, but gradually extends as the 
whole peritoneum becomes affected. As paralysis of the in- 
testines takes place marked tympanites occurs. In fatal cases 
death usually takes place within the first ten days of the 
puerperium. 

Parametritis : This complication, as a rule, develops when 
the endometritis is apparently subsiding. Its onset is fre- 
quently attended with a chill ; the temperature, which has 
probably fallen, again becomes elevated and pursues a more or 
less irregular course. The extension of the inflammatory proc- 
ess to the parametrium may usually be detected by a vaginal 
examination. The infiltrated tissues surrounding the uterus 
become hard and tense to the feel. This inflammation may 
end in resolution or in abscess-formation — one large or several 
small abscesses may form. The pus may burrow about and 
make its way into the bladder, rectum, vagina, or peritoneal 
cavity. Occasionally such an abscess may point at Poupart's 
ligament, or even above the crest of the ilium. 

Pyaemia : In cases of pyaemia the initial symptoms of in- 
fection are not so marked as in the other forms. The temper- 

23— Ob.«t. 



354 PATHOLOGY OF THE PUERPERAL PERIOD. 

ature does not remain constantly elevated, but assumes the 
hectic type. Chills are usually of frequent occurrence. 

The subsequent symptoms depend upon the organs invaded 
by the infected thrombi. Most commonly with pyaemia we 
have symptoms of an infectious bronchopneumonia developing. 
This generally proves rapidly fatal. 

In true septicssmia, which is the most virulent form of septic 
infection, the organisms make their way so rapidly into the 
general blood-current that they fail to become localized in any 
one organ. This Is the most rapidly fatal form of infection; 
death may occur on the third or fourth day of the puerperiura, 
the poison being so virulent as to induce a condition of pro- 
found shock. 

Diagnosis of Puerperal Septic Infection. 

If on the third or fourth day of the puerperal period a 
woman develops a temperature of 101° F., or more, which 
persists for twenty-four hours, the condition present is almost 
certainly one of septic infection provided there is no other ap- 
parent cause to account satisfactorily for the sym])toms. 

The most common causes of an elevation of temperature 
early in the puerperium, not associated with septic infection, 
are : constipation, irritation from the breasts, and emotional 
excitement, fright, or grief. Malaria and typhoid fever may 
complicate the puerperium, and may be confounded with septic 
infection. 

A diagnosis of malaria is only possible when the presence 
of the Plasmodium has been demonstrated in the blood. 

A diagnosis of typhoid fever is not permissible in the 
absence of Widal's blood-serum test. 

Before making a diagnosis of septic infection, careful, syste- 
matic physical examination of the patient should be made. 

A careful examination of the characters of the lochial dis- 
charge may render possible a diagnosis of which variety of 
endometritis is present in a given case of puerperal septic in- 
fection. 

In all cases the physician should make an ocular examination 
of the vulva J vagina, and cervix in a good light, employing for 
this purpose a large speculum, 



PUERPERAL SEPTIC INFECTION. 355 

As it is desirable to know what organisms are concerned in 
the production of the infection, a culture may be taken from 
the interior of the uterus. This may be accomplished with 
but little difficulty by the method recommended by Professor 
Williams, of Baltimore. 

The apparatus necessary consists of a glass tube, 20 to 25 
cm. in length and 3 to 4 mm. in diameter, with a slight bend 
at one end so as to facilitate its introduction into the uterus. 
This may be sterilized after placing it in a long test-tube of 
thick glass, which contains in its lower extremity a pledget of 
cotton-wool, while its upper end may be closed by a cotton 
plug (Figs. 123-125). 

Williams thus describes the method to be followed in ob- 
taining a culture from the uterine cavity : '' When we wish to 
make cultures from the uterus, our hands and the external 
genitalia should be thoroughly disinfected, the patient placed 
iu the Sims position, and a sterilized Sims or Simons speculum 
introduced so as to retract the posterior vaginal wall; then the 
cervix is caught with a volsellum forceps and brought down to 
the vulva ; the vaginal portion of the cervix is then carefully 
cleansed with a bit of sterilized cotton, and the sterile lochial 
tube is removed from its tube and introduced into the uterus as 
high up as it will go, care being taken to avoid touching the 
external genitals in the operation. To the end of the lochial 
tube which protrudes from the vulva a syringe, which draws 
well, is attached by means of a rubber tube. Suction is made 
whereby a certain amount of the uterine contents is drawn up 
in the tube. The tube is then withdrawn and its ends sealed 
WMth sealing-wax, when it can be carried to the laboratory 
without fear of contamination. On reaching the laboratory it 
is broken in its middle portion and cultures are taken from its 
contents, which we know represent the uncontaminated lochia 
from the upper part of the uterus.'^ 

When there is undoubted evidence of endometritis the interior 
of the uterus should be explored by means of tlie sterile finger. 
This procedure can be carried out when the culture has been 
obtained. By this means important information may be ob- 
tained which Avill indicate the line of treatment to be pursued. 
When the ivalls of the uterine cavity are rough, the probability 
is that we have to deal with a putrefactive endometritis ; or 



356 PATHOLOGY OF THE PUERPERAL PERIOD. 

Fig. 124. 






Fig. 123. 



^ 



Fig. 125. 



one due to a pyogenic organism of a low degree of virulency. 
When the cavity is perfectly smooth the infection is probably 
due to virulent streptococci or staphylococci. 



PUERPERAL SEPTIC INFECTION. 357 

Treatment of Puerperal Septic Infection. 

Prophylaxis : The occurrence of puerperal septic infection is 
to be prevented by the observance of the most scrupulous 
asej^sis in the method of conducting labor. This subject has 
been fully dealt with in the section on the management of 
labor, to which the reader is again referred. 

Prophylactic douches should not be employed except when 
the vaginal secretion presents marked evidences of abnormality. 
Vaginal examinations should be made as infrequently as possible 
during labor ; in normal cases more than one or two are seldom 
necessary. 

All vaginal and vulvar lacerations which extend deeper than 
the mucosa should be sutured immediately after the conclusion 
of labor. 

During the first two weeks of the puerperal period the most 
rigid asepsis should be observed in the care of the external 
genitals. The subject has been discussed in this work on the 
section in the management of the puerperium. 

Local Treatment. 

If on examination of the vulva sloughing surfaces are dis- 
covered, these should be painted daily with tincture of iodine. 

^yhen sutured wounds of the vaginal outlet present evidences 
of infection, the stitches should be removed in order to secure 
free drainage. 

Endometritis is the condition most frequently present in 
puerperal septic infection. 

As previously mentioned, the cavity of the uterus should be 
explored and a portion of the lochia removed for examination. 

The method of treatment to be followed will depend in a 
large measure on the conditions present in the uterine cavity. 
The indications are to remove all debris and shreds of broken- 
down tissue, and to cleanse thoroughly the interior of the uterus. 
The routine use of the curette in all cases of puerperal endo- 
metritis is mentioned only to be condemned, as in certain con- 
ditions this treatment may result in the production of far more 
harm than good. 

When the walls of the uterine cavity are found to be perfectly 



358 PATHOLOGY OF THE PUERPERAL PERIOD. 

smooth there is absolutely no indication for the employment of 
the curette, as there is nothing present that can be removed by 
it. The cavity should be douched thoroughly with a gallon or 
two of hot eterile formalin solution (1 : 500), after which a strip 
of sterilized iodoform gauze, rolled so as to form a double wick 
eight to ten inches long, may be introduced as high as the 
fundus. This wick of gauze favors drainage, and by its 
presence in the cavity stimulates the uterus to contract. Some 
obstetricians prefer to pack lightly the uterus with strips of 
gauze after douching, but this rather tends to interfere with 
free drainage, and therefore the gauze wick is to be preferred. 

If the bacteriological examination of the lochia reveals that the 
infection is due to streptococci, further local treatment is to be 
avoided and the gauze removed in forty-eight hours. 

If the interior of the uterus be found rough and jagged, and 
covered with more or less false membrane, the walls of the 
cavity should be systematically scraped with a blunt curette 
(Mund^'s), though many prefer the fingers for this purpose. 
After curetting the walls should be explored by the finger-tips 
to make sure that all debris has been removed by the curette. 
A douche of hot formalin solution (1 : 500) may then be em- 
ployed to cleanse the cavity thoroughly, after which a bougie or 
two composed of iodoform (sss) and sufficient ol. theobrom. to 
make a bougie two inches long, of the thickness of an ordinary 
lead-pencil, may be introduced as high as the fundus. These 
bougies are held in position by the gauze wicking, which should 
be introduced as recommended above. 

This treatment usually results in a marked improvement 
of the symptoms, the temperature falls within a few hours, 
and the lochia becomes more normal in type. Should the 
temperature not yield to the first injection, the treatment may 
be repeated daily, provided there is no evidence that the in- 
fection has extended beyond the uterus, in which case local 
treatment should be abandoned. 

Bichloride of mercury solution should not be employed in 
intra-uterine douches, as when this salt comes in contact with 
blood it forms an innocuous albuminate. Bumm has shown 
that bichloride injections penetrate the tissue to only a slight 
extent. The antiseptic does not remain long enough in contact 
with the infected tissue to exert much germicidal action. For 



PUERPERAL SEPTIC INFECTION. 359 

this latter reason, aucl because the main object of the douche 
is to wash away debris which has been detaclied by the curette 
or finger, many prefer to employ for this purpose simple sterile 
water or salt sohition. 

In gonococcal endometritis it is better to employ no local 
treatment, as the majority of these cases recover without it ; 
or at the worst are left with a chronic endometritis which can 
be treated to better advantage later. 

Local treatment should not be persisted in when it is evi- 
dent that it fails to improve the condition of the patient. In 
these cases all that can be done is to direct our efforts to the 
general improvement of the condition of the patient. 

General Treatment. 

These patients should receive all the food they can assimilate. 
The diet should consist chiefly of milk, eggs, and meat-juice. 
These should be given in large quantities, at short intervals, 
and if necessary should be predigested. 

The depressant action of the toxins should be combated by 
free stimulation, and for this purpose our most potent remedies 
are alcohol and strychnine. 

As much alcohol should be given as can be consumed with- 
out producing its physiological effects. It is surprising what a 
quantity of alcohol these patients can take without apparently 
producing any untoward result. 

Strychnine should also be given in large doses, from -^ to 
2^0- grain may be administered every three hours in serious 
cases. Digitalis may be combined with the strychnine when 
the pulse-rate is high. 

To control the temperature, cold wet packs should be em- 
ployed, as well as the ice-cap. As a rule, antipyretic drugs 
should be avoided on account of the depressant action they 
exert. 

Bumm has recommended the routine em})loyment of ergot 
in cases of puerperal endometritis, in order to secure better 
contraction, and thus occlude to some degree the lymphatics in 
the uterine wall. Fl. ext. ergotse (ifTLx) may be given every six 
hours, or it may be combined with quinine (gr. v) and given 
in a suitable mixture. 



360 PATHOLOGY OF THE PUERPERAL PERIOD. 

The bowels should be kept active b\' means of a daily saline 
which acts favorably by draining the pelvic lymphatics. 

The subcutaneous injection of large quantities of normal 
saline solution has been employed in the treatment of puer- 
peral sepsis with marked beneficial results. It is supposed to 
act by diluting the blood, thus favoring the expulsion of toxic 
matter. The saline solution may be injected under the breasts, 
as recommended in the treatment of hemorrhage ; or more 
conveniently into the bowel, in which case at least two quarts 
should be given at each injection. 

Recently it has been suggested that nuclein be employed in 
the treatment of these cases with a view of producing an arti- 
ficial leucocytosis. Hirst considers that this plan of treatment 
gives promise of practical results, and that more is to be 
expected of it than of serum-therapy. 

Serum-therapy : When Marmorek in 1895 published the 
results he had obtained by the employment of antistrepto- 
coccic serum in the treatment of sepsis, brilliant results were 
expected to follow its use in puerperal cases. Recent statistics 
seem to prove that the results thus far obtained by the employ- 
ment of the serum are not more favorable than those by other 
methods of treatment. 

As many cases of puerperal infection are due to other agents 
than streptococci, its routine employment in all cases can only 
be fraught with danger. When our means of diagnosis enables 
us to prove in a given case that the infection is due to the 
streptococccus alone, then the serum should be employed, but 
not to the exclusion of other methods of treatment. 

If care is taken to make an accurate diagnosis that the infection 
is due to the streptococcus alone, serum-therapy may be em- 
ployed with fair certainty of success, especially if it is used 
early and in large doses. 

Parametritis : This condition may be treated by either hot 
or cold applications, whichever prove more grateful to the 
patient. The ice-bag will be found to control the extension 
of the inflammation in many cases, while it usually relieves 
the local pain to a marked degree. When it is not well borne 
hot flaxseed poultices may be applied to the lower abdomen 
and hot vaginal douches given at regular intervals. 

Probably most of these cases heal by resolution, but a close 



EPISIOTOMY. 361 

watch must be kept for evidences of suppuration. When 
fluctuation is obtained the abscess may be opened through the 
vaginal vault when possible ; in some cases it may be neces- 
sary to make the incision through the abdominal wall. 

Peritonitis : When peritonitis develops the treatment should 
at first be expectant, in the hope that the inflammation wdll 
become localized. Counterirritation and hot fomentations to 
the abdomen, combined with the free use of saline cathartics, 
may give good results. If the symptoms progress or do not 
abate within thirty-six hours, then the abdomen may be opened 
and the case treated according to the conditions found. Ab- 
scess, if found, should be opened and drained. Distended 
tubes and ovaries should be removed, and under certain con- 
ditions it may be necessary to perform hysterectomy. 

The indications for hysterectomy are the presence of multiple 
abscesses in the uterine walls ; and putrid endometritis which 
fails to yield to repeated intra-uterine irrigations and curetting. 

Phlegmasia alba dolens : The patient should be kept in bed 
with the aifected limb elevated so as to favor the return circu- 
lation. The limb should be wrapped in cotton and bandaged 
loosely. The general treatment should be supporting and stimu- 
lating. 

In the cellulitic variety suppuration is very likely to take 
place in the connective tissue of the thigh. Abscesses should 
be watched for and promptly opened, so as to avoid burrowing. 

OBSTETRIC OPERATIONS. 

Episiotomy. 

Definition : Episiotomy is the term applied to any incision 
of the external genitals to prevent extensive laceration taking 
place during the passage of the child at the time of birth. 
The operation cannot be said to be in general use in this 
country, but is common in Germany and Austria. 

Indications : These are : 

1. Threatening central rupture of the perineum. 

2. Great narrowness of the external genitals. 

3. Rigidity of the perineum, especially when due to cica- 
tricial tissue. 



362 OBSTETRIC OPERATIONS. 

4. Faulty position of the advancing part of the foetus at the 
outlet. 

5. Undue size of the foetal head. 

Operation : Tarnier has recommended an oblique incision 
passing to one or other side of the anus. The Germans pre- 
fer lateral oblique incisions directed toward the posterior com- 
missure. It is stated that such an incision 1 cm. (| inch) in 
length increases the circumterence of the vulvar orifice 2 cm. 
(f inch). 

The instrument used is a blunt-pointed scissors. During a 
pain one blade of the open scissors is slipped sideways between 
the head and the vulva, and then turned and the tissues cut. 

Tlie advantage of episiotomy is the substitution of a clean cut 
of definite size, in a place where it can do no harm, for an ir- 
regular laceration of indefinite size which may cause perma- 
nent injury to the patient. Also a clean incision is much more 
easily sutured than a jagged laceration. 

IMMEDIATE REPAIR OF VAGINAL AND PERINEAL 
LACERATIONS. 

Whether the pelvic fascia or the fibres of the levator ani 
muscles are the all-important structures concerned in the support 
of the internal pelvic structures is still a matter of debate. 
It is, however, certain that the wedge of tissue between the 
vagina and rectum composing the perineal body has practically 
nothing to do with the support of the pelvic contents. 

According to Kelly, the ^' real supporting mechanism " of 
the outlet is the anterior portion of the levator ani muscle. The 
more generally held opinion, however, is that the pelvic fascia 
is the supporting mechanism of the outlet, and that the sheets 
forming the ischioperineal layer of the rectovesical fascia are 
most important in this connection. 

When it is considered that the vaginal orifice, normally 2 to 
3 cm. in circumference, is dilated to 33 cm. at the moment of 
delivery to permit the passage of an ordinary sized child, it is 
not surprising that laceration commonly takes place. 

As a matter of routine, after the conclusion of labor, the 
physician should carefully examine the vulva and vaginal ori- 
fice for lacerations. This examination may ordinarily be made 






REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 363 

with the patient in the dorsal position, having the thighs 
everted. A good light is absolutely necessary. When an ex- 
ternal superficial tear is found it may be repaired at once, as 
directed below. 

If, however, an extensive laceration should be present, further 
examination may be delayed until preparations have been com- 
pleted for a repair operation. 

Injuries to the vaginal outlet the result of childbirth may be 
classified as follows : 

1. External superficial tear. 

2. Internal tear, or combined internal and external tear. 

3. Complete tear of the rectovaginal septum. 



Fig. 126. 



1. External Superficial Tear. 

This form of injury from parturition is the most frequent 
and also the least important, as it in no way affects the sup- 
porting structures of the pelvic outlet. 

The tear involves simply the su])erficial 
portion of the wedge of lax tissue between 
the vagina and rectum. It begins at the 
introitus vaginae and extends backward 
through the skin in the median line; occa- 
sionally it may extend inward as far as the 
posterior column of the vagina (Fig. 126). 
This laceration can be inspected through- 
out its whole extent by merely separating 
the labia. 

When the tear simply extends through 
the fourchetfe strict cleanliness until it has 
healed is all that is required. 

When the laceration has a base 2-3 cm. 
(} to 1^ inches) in length it should be 
sutured immediately. 

When possible, it is the writer's habit 
to suture these tears while waiting for the 
detachment of the placenta, as the patient 
at that time is still more or less under 
the influence of chloroform. During the slight operation the 
nurse is placed in charge of the fundus. 




Superficial tear ex- 
posed by fingers parting 
labia minora. 



364 OBSTETRIC OPERATIONS. 

Instead of tying the sutures at once, the ends may be caught 
in a pair of forceps and the tying completed after the delivery 
of the placenta. 

Necessary for the operation : A couple of small curved nee- 
dles, a needle-holder, three or four silkworm-gut or silk sutures, 
and a pair of scissors should be sterilized. Many prefer to 
employ an 'Emmett perineum-needle in suturing these lacera- 
tions; it consists of a needle with a large curve, mounted on a 
handle ; the needle is passed, threaded, and then withdrawn. 

The rule is to place the patient across the bed with the but- 
tocks over the edge, the legs being flexed over the backs of 
two chairs properly arranged. In many cases it is possible to 
suture these simple lacerations without disturbing the patient 
beyond separating and everting her thighs. 

Suturing : The patient being placed as most convenient, the 
lips of the tear are held apart by the fingers of the left hand, 
the threaded needle is then introduced near the upper angle of 
the wound about J cm. [\ inch) from its margin, brought out 
at the floor, and reentered, to emerge on the skin surface op- 
posite the point of entrance. A similar suture is then placed 
near the lower angle, and both sutures tied after the wound 
has been cleansed. 

If the approximation is not quite satisfactory, one or two 
superficial sutures may be required. The end of the sutures 
should be left fairly long, so that they may be easily found 
and prevented from causing the patient inconvenience by 
pricking. The sutures may be removed on the eighth day. 

2. Internal Tear, or Combined Internal and External 

Tear. 

Conditions : An internal tear when present is found to ex- 
tend from the fourchette inward from one to two inches, in- 
volving one or both lateral sulci (Fig. 127). This tear always 
destroys the integrity of the pelvic supporting structures, and 
if neglected leads to serious results. 

Such an internal laceration may be present witliout an ex- 
ternal wound; but usually the external injury (already de- 
scribed) is to be found associated with the internal tear when 
it is present. On inspection a ragged bleeding wound will be 



REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 365 

found in the posterior vaginal wall, associated probably with 
more or less external laceration. 

Method of Repair. 
The patient should be placed across the bed with the but- 
tocks over the edge, as previously described. 




Superficial combined internal and external tear, showing portion of tear in vagina 
that may escape notice. 

The illumination of the field of operation should be the best 
obtainable. 

Unless the patient is prepared to suffer a little pain, an an- 
aesthetic, preferably ether, should be administered. Through- 
out the operation an assistant should guard the fundus uteri to 
prevent relaxation. 

The instruments required are the same as before mentioned, 
with the addition possibly of a couple of vaginal retractors. 



366 



OBSTETRIC OPERA TIONS. 



Fig. 129. 



The first step in tlie operation is to ascertain the nature and 
extent of the Jaceration. To obtain a good view, it may be 
necessary to pack the upper part of the vaginal canal with 
sterile gauze or cotton to prevent the flow of blood from above. 
All ragged and badly bruised tissue should be then cut away, 
and the upper angle of the wound exposed by means of the 
fingers of the left hand or by a retractor held by an assistant. 

The suturing should commence at the upper angle of the 
tear, and the sutures should be about a centimetre apart ; as 
many should be employed as 
are required to bring the edges 
of the wound, or wounds, well 
together. 

The method of inserting the 
sutures is of very considerable 
importance, as the object is to 
secure the union of the sup- 
porting structures of the pelvic 
floor (Fig. 128). The needle 
should be introduced on the 
mucous surface 0.5 cm. (i 
inch) from the margin of 





Same as Fig. 127, with internal sutures 
passed, ready to tie. 



Internal stitches tied ; external stitches 
in position. 



the wound and directed through the tissues in the direction 
of the outlet, brought out at the base, then reintroduced, and 
directed inward and upward so as to emerjj^e on the mucous 
surface at a point opposite its insertion. Thus the loop of 



REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 367 

each suture when in place is directed toward the operator (Fig. 
129). 

Each suture should be tied before the next is introduced. 
The last suture thus introduced should bring together the 
torn edges of remains of the hymen at the vaginal orifice. 

The external wound may then be repaired by a few super- 
ficial sutures introduced from the skin surface. 




Complete tear, involving the rectovaginal septum. 

Dressing : The temporary gauze tampon may then be removed, 
a vaginal douche given, and the wound dusted with an anti- 
septic poAvder before the vulvar pad is ap]^lied. 

After-treatment: The wound should be kept well dusted 
with iodoform and boric acid powder (1:7), constipation 
should be avoided, and the patient forbidden to strain while 



368 



OBSTETRIC OPERATIONS. 



having a motion of the bowels. If there be much tension on 
the suture, catheterization may be necessary in order to relieve 
the bladder. The sutures may be removed on the eighth or 
tenth day, but the patient should be kept in bed for at least 
fourteen days. 

3. Complete Tear. 

Conditions : A complete tear of the perineum is one extend- 
ing from the fourchette backward through the sphincter ani, 
and involving the rectovaginal septum to a greater or less 

Fig. 131. 




Complete tear ; closing the rent in the bowel. 

extent (Fig. 130). Such tears involve destruction of the 
function of the sphincter ani muscle, and result in inconti- 
nence of faeces and flatus. The condition of the patient thus 
becomes most distressino^. 



Operation. 

Anaesthesia in this instance is imperative for the proper per- 
formance of the operation. 



REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 369 

The position of the patient should be as for the previously 
described operation. The nature and extent of the wound 
should be first ascertained and the field of operation thor- 
oughly cleansed. 

The rectum is first repaired by means of interrupted catgut 
sutures introduced from the mucous surface. The ends of the 
sphincter must be carefully approximated by means of buried 
catgut sutures. 

The vaginal rent should then be repaired as before recom- 
mended ; and, finally, the shin surfaces of the perineal wound 
must be brought together. 

Fig. 132. 




Deep interrupted lifting sutures in position. 



It is well to reinforce the catgut sutures uniting the torn 
ends of the sphincter, by means of a large suture of silkworm- 
gut introduced on the skin surface so as to include in its loop 
a considerable portion of the muscle as well as of the septum 
above it (Figs. 131-134). 

After-treatment: Constipation should be avoided, the 

24— Obst. 



370 



OBSTETRIC OPERATIONS. 



bowels being opened on the third day and every second day 
afterward. An oil enema should be given just before a move- 
ment is expected, and the edges of the wound should be sup- 
ported by the nurse, the patient being warned not to strain 
force while evacuation is taking place. The wound 



nor 



Fig. 133. 



Fig. 134. 





All sutures laid ; vaginal sutures tied. 



Interual and external sutures tied. 



should be kept well cleansed and dusted with an antiseptic 
powder. The sutures may be removed on the tenth to the 
twelfth day. The patient should remain in bed for three 
weeks. 



IMMEDIATE REPAIR OF CERVICAL LACERATIONS. 

Lacerations of the cervix are rarely repaired unless the cir- 
cular artery is involved and severe hemorrhage results. 

Cervical lacerations, even when severe, frequently heal by 
first intention without operation. 

Operation : The oj)eration can usually be performed without 
difficulty. The patient is placed as recommended in the pre- 



I 



INBUCTIOX OF ABORTION. 371 

vious operations, the cervix is seized with a tenaculum, drawn 
down, and held in position for suturing. 

The sutures should be placed about one inch apart, and the 
first should be placed at the upper angle. Silkworm-gut 
should be employed, and the stitches may be removed on the 
twenty-first day. 

INDUCTION OF ABORTION. 

Definition : By the induction of abortion is meant the arti- 
ficial emptying of the uterus before the period of viability 
of the child is reached — that is, before the end of the twenty- 
eighth week of pregnancy. Some authors limit the term 
" induction of abortion " to the emptying of the uterus before 
the end of the sixteenth week, because the methods of opera- 
tion differ before and after this period. 

Indications : The occurrence of pathological conditions con- 
sequent upon pregnancy, and the aggravation of certain dis- 
eases by gestation, give rise occasionally to the necessity of 
emptying the uterus by artificial means at the expense of the 
child's life in order to save the woman. Among the con- 
ditions which may render necessary the induction of abortion 
the following may be mentioned : 

1. Hyperemesis gravidarum. 

2. Renal insufficiency, with threatened eclampsia. 

3. Death of the foetus. 

4. Insanity, resulting from or aggravated by pregnancy. 

5. Incarceration of a retroflexed uterus. 

6. Presence of benign or malignant tumors which w^ould 
preclude the delivery of a viable child or render Csesarean 
section at term inadvisable. 

7. Acute hydramnios and cystic degeneration of the 
chorion. 

8. Certain blood diseases, as leucocythsemia and pernicious 
anaemia. 

9. Rarely hemorrhage from placenta prsevia may render 
necessary the termination of pregnancy before the period of 
the viability of the child is reached. 

The attending physician should consult with a colleague 
before deciding the question of interference, and a full ex- 



372 OBSTETRIC OPERATIONS. 

planation of the circumstances of the case should be made to 
the members of the family most directly concerned. 

Methods of Inducing Abortion. 

The administration of drugs internally for the purpose of 
inducing abortion is only mentioned to be condemned. Their 
action is slow and uncertain, and their use is not infrequently 
attended with danger. 

Up to the end of the sixteenth week the quickest and most 
certain method of terminating the pregnancy is the following : 

Dilating the Cervix and Curetting the Uterine Cavity. 

Advantages : The operation can be done in from ten to 
twenty minutes ; it is certain in effect, and when properly car- 
ried out it is practically unattended with danger to the 
patient. 

The instruments required for this operation are, a volsellum 
forceps, a Simon perineal retractor, a set of Hegar's dilators, 
a pair of branched dilators, such as Goodell's, an Emmet 
curette-forceps, a sharp curette, and a pair of long uterine 
dressing-forceps. Some strips of iodoform gauze (10 per 
cent.) for packing the uterine cavity and vagina should also 
be prepared. 

Preliminary to operation : The patient, after being anaesthe- 
tized, is placed in the lithotomy position on a table which is 
in a good light, the limbs being held in position by means of 
a rolled sheet or by a crutch. The vagina and vulva are then 
scrubbed with spirits of green soap and hot water, cotton-wool 
swabs being employed. The parts are then disinfected by 
means of a douche of 1 : 500 formalin solution. The hands 
of the operator are then sterilized. 

The operation : The perineal retractor is placed in the va- 
gina, and the anterior lip of the cervix seized with a volsellum 
and drawn well down. These instruments may then be held 
by an assistant. The cervix is then dilated by means of 
Hegar's and Goodell's dilators till it easily admits the fore- 
finger. The Emmet curette-forceps is then inserted into the 
uterine cavity and the ovum seized and crushed before the 



INDUCTION OF PREMATURE LABOR. 373 

instrument is withdrawn with wliatever may have been 
grasped. The fcetiis and as much of the rest of the ovum as 
is possible should be removed by these forceps ; after which 
the uterine walls should be carefully and systematically 
curefted, but without much force. 

After operation : The uterine cavity is then douched with 
hot formalin solution, and afterward packed with iodoform 
gauze. The volsellum and perineal retractor are then removed 
and the operation is completed. 

Some operators prefer not to empty the uterus at one sitting, 
but after removing the foetus to pack the cervix with gauze 
and to tampon the vagina with antiseptic wool, Avhich are left 
in place for twenty-four hours. On their removal, if the 
remainder of the ovum is not discharged from the os, the cer- 
vix being softened by the tampon, is further dilated and the 
uterine cavity is thoroughly curetted ; and is then douched 
and packed with gauze as above recommended. This gauze 
packing should be removed in from twenty-four to thirty-six 
hours. 

The patient should be kept in bed from one week to ten 
days after this operation. 

Abortion, when induced after the sixteenth week is accom- 
plished by means of the methods to be recommended for the 
induction of premature labor. 

INDUCTION OF PREMATURE LABOR. 

The indications for the induction of premature labor are 
much the same as those given for the induction of abortion. 
In addition, however, may be mentioned contracted pelves in 
which it is desired to avoid the necessity of C?esarean opera- 
tion or symphysiotomy. Placenta prsevia, while a rare indi- 
cation for abortion, not infrequently necessitates the induction 
of premature labor. 

It may be necessary to induce labor prematurely in ad- 
vanced heart disease and in tuberculosis. 



374 OBSTETRIC OPERATIONS. 

Methods of Inducing Premature Labor. 

Krause's method : This is the simplest and the most satis- 
factory in the vast majority of cases. It consists in the intro- 
dactlon of a bougie into the uterine cavity between the mem- 
branes and the wall of the uterus. 

One or two bougies (No. 10 or 12 English) are sterilized by 
soaking for an hour in a cold solution of formalin 1 : 500. 
The patient is prepared by having the vulva and vagina 
washed and douched as previously described. She is then 
placed in the dorsal position across the bed with her feet on 
two chairs. The operator, after sterilizing his hands, intro- 
duces two fingers of his left hand into the vagina as far as 
the external os. A bougie anointed with carbolized vaseline 
is then guided along the fingers into the cervix and pushed 
steadily up until only an inch or so remains outside the ex- 
ternal OS, care being taken not to rupture the membranes. 
Sterile gauze is then packed about the butt of the bougie, to 
keep it in place and to prevent injury of the posterior vaginal 
wall. If at the end of twenty-four hours labor-pains have 
not manifested themselves, the gauze and bougie should be 
removed, the vagina douched, and another bougie inserted. 

Tarnier's method : This consists in the dilatation of the cervix 
and the introduction of dilatable rubber bags. Tarnier's bag 
is an oval affair, to which is attached a long rubber tube with 
a stopcock. The bag is introduced by means of a special for- 
ceps, and then dilated by pumping in sterilized water. 
Barnes's bags may also be used for this purpose, though the 
best bag in shape and material is probablv Champetier de 
Ribes'. 

Many other methods have been recommended for the induc- 
tion of premature labor, but the methods described are practi- 
cally the most commonly employed. 

FORCEPS. 

History : It is probable that the obstetric forceps in crude 
form were employed before the Christian era. The instru- 
ments seem to have fallen into disuse and were practically 
unknown in the middle ages. 



FORCEPS. 



375 



The invention of the modern instrument is generally cred- 
ited to one Peter Chamberlan, the son of a French Huguenot 
physician, who had settled in England. The obstetric forceps 
remained a family secret with the Chamberlans for three gen- 
erations. It was not till 1725 that the secret of the Chamber- 
Ian family leaked out in England and the obstetric forceps 
became public property. 

These forceps had only the cephalic curve, which permitted 
a firm grasp of the head. Later, Smellie in England and 
Levret in France improved 

the forceps by adding a Fig. 135. 

second curve, which adapted 
the instruments to the curva- 
ture of the pelvic cavity. The 
modern forceps are simply im- 
proved models of those in- 
vented by Smellie and Levret. 

Description : The obstetric 
forceps consists of two inter- 
locking branches or blades, 
each of which is provided 
with a handle to facilitate 
traction. 

The blades are usually fen- 
estrated, and have a double 
curve, a cephalic, adapting 
them to the shape of the 
foetal head, aud a pelvic, ac- 
commodating them to the 
shape of the pelvic canal. 

The articulation of the 
blades is in the form of an 
open lock in the English 
models, while the Conti- 
nental models generally have 
the French lock, which con- 
sists of a mortise and tenon 
tightened by means of a 
screw. The English lock, having the advantage of easy 




Simpson's long forceps. 



376 



OBSTETRIC OPERATIONS. 



adjustment, is to bo preferred to the more complicated and 
rigid French lock. 

The JunuJles of the forcej)s are usually serrated or grooved 
transversely, to give a better hold. In the better models the 
handles are })rovided with projecting shoulders to facilitate 
traction. A good ohstetric forceps should be made of well- 
tempered steel, polished and heavily nickel-plated throughout. 
The edges of the blades and the fenestra should be rounded 
and smooth. In England and America the favorite forceps 
is the Simpson-Barnes. It has the Barnes blades and the 
Simpson handles (Fig. 135). 

The loriter has found that for general use the most satis- 
factory obstetric forceps is Dr. Cameron's model of the Simp- 
son-Barnes instrument. Dr. Cameron has modified the pelvic 



Fio. 136. 




Cameron's model of Simpson-Barnes forceps. 



curve of the blades in such a manner as to permit a much 
more secure grasp of the foetal head being obtained than is 
the case in other models (Fig. 136). 

For low operations a simple, light instrument, such as 
Sawyer's, is very useful. 

In high operations the line of traction must correspond as 
^ J. IT. Chapman, Montreal. 



FORCEPS. 377 



much as possible to the axis of the pelvic inlet. In such 
operations a great amount of traction force is lost because it is 
impossible to get the handles of the ordinary forceps back far 
enough on account of resistance offered by the perineum 
This difficulty has been overcome by the invention of the 
axis-tradion forceps by Taruier, in 1877 (Fig. 137). By 



Fig. 137. 




Tarnier's axis traction forceps. 



means of traction rods attached to the base of each blade, 
fitting at their lower ends into a specially curved perineal 
bar, to which is attached a cross-bar as a handle, the line of 
the traction force is brought into relationship wnth the axis 
of the brim. The Tarnier forceps is so constructed that 
when the lower ends of the traction rods are held 1 cm. from 
the shanks the line of the pull will be in the axis of the birth- 
canal no matter what the position of the blades may be in the 
pelvis. 

^lany other models of axis-traction forceps have been in- 
vented, but none has proved so generally satisfactory as the 
Tarnier. 



378 OBSTETRIC OPERATIONS. 

Indications for the Use of Forceps. 

In general terms it may be stated that the faihire of a 
woman to deliver herself, when delay in delivery will en- 
danger the life of the mother or the child, or both, is an indi- 
cation for the employment of forceps to terminate labor. 

Anomalies of the mechanism of labor resnlting in failure 
of the presenting part to advance have been fully discussed 
in detail. 

Other indications : Insufficient expulsive power, as uterine 
inertia from whatever cause ; increased resistance in the pel- 
vic canal from moderate pelvic contraction or from unusual 
rigidity of the soft structures ; over-size or undue ossification 
of the foetal head ; abnormal presentations or positions of the 
foetal head, as face presentation and occipitoposterior positions; 
accidental conditions, such as eclampsia, placenta prsevia, pro- 
lapse of the funis or of a foetal member. 

Exhaustion of the mother is evidenced by a steady increase 
in the rapidity of the pulse-rate, rising temperature, and a 
progressive failure in the force of the uterine contractions. 

Danger to the child is indicated by the foetal heart beats 
becoming rapid and weak or slow and feeble. 

If in the course of the second stage of labor the head fails 
to advance, and, either because of feeble contractions or from 
increased resistance, is arrested for half an hour, the labor 
should be terminated by forceps. 

When forceps are indicated the following conditions must 
be present to render the application of the blades permissible : 

1. The OS must be completely dilated or easily dilatable; 

2. The membranes must be ruptured ; 

3. The child must be living and viable; 

4. The head must be engaged in the brim ; or it must 
be possible to crowd the head down to the pelvic inlet by 
external pressure; 

5. The head must be of average size and consistence, or 
else the blades will not retain their hold ; 

6. The relative proportion between the head and the pelvis 
must be such as to make extraction possible with safety to 
mother and to child ; 

7. The position of the head must be favorable ; for instance, 



FORCEPS. 379 

it is practically impossible to deliver a mentoposterior position 
of the face. 

Preparation for the Forceps Operation. 

Instruments, etc. : The obstetric forceps, as well as such in- 
struments and sutures as may be required for the repair of 
lacerations subsequent to deliyery, should be wrapped in a 
clean toM'el and boiled for ten minutes, after which they may 
be placed in a basin containing cold sterile water, to cool off. 

Preparation of the patient : The bladder and rectum should 
be emptied ; after which the abdomen, thighs, and external 
genitals should be rendered as aseptic as possible. If there 
be reason to suspect contamination of the vagina, the internal 
passages should be thoroughly scrubbed and douched as for a 
surgical operation. The lubricity of the parts may then be 
restored by the application of sterilized glycerin or vaseline. 

AA^hen the operation has to be done with the patient in bed, 
a Kelly pad or rubber sheet should be arranged under the 
patient's hips so as to conduct all discharges into a baby's 
bath-tub or other vessel on the floor. The j^cifienfs limbs 
should then be wrapped about with freshly laundried or ster- 
ilized sheets. 

The operator's hands and forearms should be sterilized, and 
he should wear either a sterilized apron or a sheet, to protect 
his clothing. 

Preliminary to operation : The operator should then sit 
down facing the genitals of his patient. Close to his hand 
should be placed his instruments and a basin containing a 
weak formalin solution (1 : 1000), as well as some pieces of 
sterilized gauze or a plentiful supply of clean towels. 

Before proceeding to apply the forceps the quality and 
frequency of the foetal heart-beats should be ascertained and 
an exact knowledge of the position and charade}' of the fcetal 
head obtained. For this latter it may be necessary to pass 
the entire hand into the uterus ; hence the patient should be 
anaesthetized before making this examination. Any mal- 
position of the head should then be altered if possible before 
the application of the blades is attempted. 

Anaesthesia : It is rarely possible to employ the obstetric 



380 OBSTETRIC OPERATIONS. 

forceps satisfactorily unless the patient is under the influence 
of an anaesthetic. For prolonged or difficult cases ether 
should be used in preference to chloroform, and its adminis- 
tration entrusted to a medical assistant. 

Posture of the Patient. 

The application of the obstetric forceps is possible with the 
patient either in the dorsal or in the left lateral position. 
Many consider that the application of the forceps is more 
difficult in the left lateral than in the dorsal position ; but 
this difficulty is more apparent than real. 

Generally speaking, the lateral position offers many advan- 
tages, especially if the operator lacks a skilled assistant. In 
this position the patient's limbs do not require to be sup- 
ported. The application of both blades is accomplished with 
the right hand, while the fingers of the left hand placed 
within the vagina serve to guide both the blades into position. 
During traction the perineum is under constant observation, 
and extraction is easier and safer. 

Walcher's position : On account of the increased mobility 
of the sacro-iliac joints in the latter months of pregnancy a 
certain limited amount of rotation of the sacrum is possible 
on a transverse axis passing through its second vertebra. 

After experiments with the live subject and with the 
cadaver, Walcher demonstrated that by placing the woman at 
full term on a table in the dorsal position with the buttocks 
close to its edge, and the lower limbs hanging unsupported, 
the conjugate diameter is lengthened by from one half to 
one centimetre. This posture of the patient is known as 
Walcher's position. The posture may be utilized to advan- 
tage in high forceps operations or in difficult versions. 

The Forceps Operation. 

There are two methods of application of the forceps. That 
known as the EnglM method is to apply the blades so as to 
correspond to the sides of the pelvis, quite regardless of the 
position of the head. 

The Continental method is to apply the blades to the sides 
of the child's head regardless of the pelvis. 



FORCEPS. 381 

Tlie pelvic application of the blades — i. e., the English 
method — is on the whole safer and better, as less damage is 
possible to the maternal soft parts. 

The cephalic application of the blades — i. c, the Continental 
method — shonld only be employed by experienced and expert 
operators, as it is the more complicated and difficult. 

The operation is divided into the high, the medium, and the 
low, according to the position of the head in the pelvis. 

In the high operation the head is arrested at or just engaged 
in the pelvic brim. In the medium operation the head is 
arrested well within the pelvic cavity. In the loic operation 
the head rests upon the pelvic floor. 

In high operations the axis-traction forceps should be em- 
ployed, and the patient should be placed in AValcher's position 
until the head has been drawn down into the pelvic cavity. 
As a rule, it is more convenient for the operator and better 
for the patient if she be placed on a table for the high forceps 
operation. 

In medium and low operations the patient may be placed 
either in the left lateral or in the dorsal position, whichever 
is more convenient for the operator. 

Forceps Operation in the Dorsal Position. 

The patient having been prepared for the operation, is 
placed in the dorsal position, across the bed with the buttocks 
projecting slightly over the edge. 

Support of the limbs : ^yhen assistants are not obtainable to 
hold the limbs, they may be supported as in the lithotomy 
position by means of a rolled sheet passed under the neck 
and over one shoulder, having the ends fastened at the 
patient's knees. 

A better method is to place two ordinary wooden chairs a 
short distance apart with their backs to the edge of the bed. 
The patient's knees are then flexed over the backs of the 
chairs, fokled towels being so placed as to protect the pop- 
liteal regions from injury. The operator sits facing the 
patient. 

Introduction of the blades: Having made an internal ex- 
amination and having satisfied himself as to the exact position 



382 OBSTETRIC OPERATIONS. 

of the foetal head, the operator selects the left, or lower, blade 
of the forceps, which he grasps close to the shaft with the 
fingers of the left hand, holding the instrument as he would a 
pen. Two or more fingers of the r'ujM hand are inserted 
within the vagina, and if possible, within the cervix, their 
palmar surfaces being in contact with the child's head. The 
fingers are carried as high as it is possible to introduce them, 
and the maternal soft parts held outward away from the head. 

The left blade is then held perpendicularly to the woman's 
body, and the tip is guided along the fingers of the right 
hand within the vulva. No force is required to introduce 
the blade^ which is guided along the fingers of the internal 
hand, by slowly sweeping the handle downward along the 
internal surface of the mother's left thigh. This blade when 
in position rests between the head and the left lateral wall of 
the pelvis. 

The upper blade is then held in the right ha,nd in similar 
fashion, and is guided along the fingers of the left hand 
within the vagina, the handle being depressed along the 
mother's right thigh. 

The forceps are then locked by depressing the handles 
toward the perineum and gently rotating the blades into posi- 
tion. Care should be taken not to include hair or a portion 
of the vulva in the bite of the lock. In guiding the blades 
into position it is important to have the fingers of the internal 
hand introduced as far as possible and to press the maternal 
tissues well to one side. 

After locking the forceps a careful internal examination 
should be made to ascertain if a good grasp of the head has 
been obtained, and that nothing but the head has been in- 
cluded in the bite of the forceps. The handles are then 
fjrasped near the lock with one hand, the fingers being hooked 
over the projecting shoulders while the back of the hand is 
directed upward. 

Extraction is effected by steady pulling, or, better, by exert- 
ing a slight pendulum movement at the same time. 

The line of traction should corres]wnd to the axis of the 
plane of the pelvis in which the head is engaged ; thus in high 
operations the line of traction is directly backward to cor- 
respond to the axis of thfe brim ; in medium operations the 



FORCEPS. 383 

line of traction is directly horizontal ; while in loiv operations 
it is upward, so that the handles are directed toward the 
mother^s abdomen. 

The tractions should be intermittent, like the natural pains. 
A good rule is to pull for one minute and then to rest for 
two. During the intervals it is better to unlock the forceps, 
so as to relieve the head from pressure and also to favor its 
rotation as it descends. 

Traction, when once the perineum begins to distend, must be 
made very carefully in order to avoid the sudden descent of 
the head. 

The line of traction should be pretty much liorizontal until 
the occiput pivots under the pubic arch. After this has 
occurred no further traction is necessary, but the head is slowly 
and carefully extended by pushing the handles upward in the 
direction of the mother's abdomen. 

When the head can be retained In the perineum by pressure 
applied from behind in the coccygeal region, the forceps may 
be gently removed and the head delivered without them. The 
head Is held In position by grasping it through the perineum 
with the left hand. On no account should the fingers be 
inserted into the anus for this purpose, as it is unnecessary 
and dangerous to do so. 

When the head can be held in position the blades may be 
removed in the reverse order of their application. The utmost 
gentleness sliould be employed in their removal, and no force 
should be exerted if any obstacle be encountered. When 
gentle manipulation fails to release a blade, it should be left in 
place until the head is delivered. 

After the forceps have been removed the head can be 
delivered by pressure over the perineum. 

As a general rule, forceps operations are performed with 
excessive speed, hence the frequency of lacerations of the 
maternal soft parts following their employment. 

Axis Traction. 

In high operations axis-traction forceps should be used, 
though a certain degree of axis traction may be obtained with 
the ordinary forceps ; as will be described later. 



384 



OBSTETRIC OPERATIONS. 



The patient having been placed on a table in the dorsal 
position, with the buttocks at the edge and the limbs held by 
assistants, or supported by chairs, the blades are inserted in 
the ordinary manner with the traction-bars fastened (Fig. 
138). After insertion the blades are locked, and, if Tarnier's 



Fig. 138. 




Guiding-hand and forceps blade ; high application. (Faraboeuf and Varnier.) 

instrument is used, the lock-pin is screwed moderately tight. 
The bar connecting the handles is then thrown across, locked, 
and the screw tightened until the blades have secured a firm 
but not too tight grasp of the foetal head. The lower ends of 
the traction-bars under the shanks are then loosened and 
the perineal handle adjusted to them and locked. 



FORCEPS. 



385 



After ascertaining that a proper grip of the head has been 
obtained and that the various screws are properly adjusted 
without the inclusion of portions of vulvar tissue the patient 
can be placed in the Walcher position by removing the sup- 
ports from her limbs. By placing large blocks or books 
under the table-legs nearer the operator the table can be 

Fig. 139. 




Traction with axis-traction forceps. 

inclined in such a manner that the buttocks will not be pulled 
too far over the edge when traction is exerted. The line of 
traction should be downward and backward as far as possible, 
the traction-rods being kept about a quarter of an inch from 
the shanks throughout the pull (Fig. 139). 

Between the tractions, the connecting-bar between the 

25— Obst. 



386 OBSTETRIC OPERATIONS. 

handles should be unscrewed and the pin-lock loosened in 
order to relieve the foetal head from continued pressure. 

When the head has been drawn down to the pelvic floor 
there is no further need either for the Walcher position or 
for the axis-traction rods. The patient may then be placed in 
the ordinary position, the perineal handle may be removed, 
and the traction-rods fastened in their places beneath the 
blades, the forceps then being used as the ordinary instru- 
ment. Some operators prefer to remove the Tarnier instru- 
ment as soon as the head reaches the pelvic floor, completing 
the delivery by means of Sawyer's small forceps. 

In high operations a certain amount of axis traction can be 
exerted with the ordinary long forceps. By Paget's or 
Galabin's manoeuvre the line of traction can be brought to 
correspond fairly well with the axis of the pelvic inlet. 

Thus by pressing or pulling downward with one hand 
placed as near the shanks as possible, and by pressing or 
pulling upward with the other hand on the handles, two 
forces are brought into action, with the effect that the 
resultant acts in the line of descent of the head. The forceps 
by this manoeuvre is used as a lever, the hand grasping the 
shanks being the fulcrum. 

In employing this manoeuvre the greatest care must be 
exercised to prevent the blades slipping. 

Forceps Operation in the Left Lateral Position. 

The patient is placed somewhat obliquely across the bed, 
lying on her left side with her thighs well flexed, the hips 
being brought well over the right edge of the bed. A folded 
pillow may be placed between her knees to keep the thighs 
separated. The operator sits facing the patient's buttocks. 

The preparations for the operation are otherwise the same 
as mentioned in dealing with the application of forceps in the 
dorsal position. 

Insertion of the blades : Two fingers of the operator's left 
hand are inserted along the posterior wall of the vagina, 
through the cervix when possible and well over the present- 
ing part, pivoting the finger-tips upon the head globe, while 
the cervix, the posterior vaginal wall, and the perineum are 
pressed back as far as possible out of the way. 



FORCEPS. 



387 



The lower blade being held in the right hand with the 
pelvic curve directed backward, so that the tip of the instru- 
ment is in contact with the left hand, is thus introduced 
within the vagina. To facilitate the introduction of the tip of 
the blade in this position, the handle must be held low down, 
corresponding to the direction of the gluteal fold of the 
patient's left buttock (Fig. 140). As soon as the tip of the 
blade has been guided by the fingers of the left hand over the 

Fig. 140. 




Position of patient for forceps delivery and mode of introducing lower blade. 

(Playfair.) 



convexity of the head the handle is raised, being swept up- 
ward over the mother's right thigh, and finally backward and 
downward, until the shank falls behind the operator's left 
wrist. The handle thus sweeps through nearly three-quarters 
of a circle as the blade is being introduced and pushed up. 
This movement of the liandle causes the tip of the blade to 
sweep around and under the head. 

ThQ fingers of the left hand remain in contact with the head 
throughout the insertion of both blades, the first blade being 



388 



OBSTETRIC OPERATIONS, 



held in position after its introduction by resting against the 
back of the left wrist while the second is being manipulated 
into position. 

^ The upper blade is then grasped in the right hand and its 
tip introduced into the vulva above the shank of the first 
blade with the pelvic curve directed forward. The tip is 
guided into position over the convexity of the head by the 
fingers of the left hand (Fig. 141). The handle is then swept 

Fig. 141. 




Introduction of the upper blade. (Playfair.) 

downward and backward along the mother\s left thigh^ thus 
causing the blade to move around the upper surface of the 
head to take its position opposite the right ilium. 

The second blade, having been placed in position, is used 
as a guide in locking the handles. It is held steady while 
the first blade, which may become displaced during the intro- 
duction of the second, is manoeuvred into position so as to 
lock (Fig. 142). 

Extraction : After examination to see that all is secure, the 
operator, grasping the handles over the projecting shoulders 



J 



FORCEPS. 



389 



with his right hand, exerts traction as far backward as pos- 
sible, at the same time steadying the patient's hips with his 
left hand. During extraction in the lateral position the 
handles describe a horizontal arc from left to right. 



Fig. 142. 




Forceps in position. Traction in the axis of the brim, downward and backward. 

(Playfair.) 

When the head can be retained in the distended perineum 
the forceps may be gently removed and the delivery com- 
pleted without them. 

Forceps in Persistent Occipitoposterior Cases. 

Ordinarily, when it is necessary to terminate labor by means 
of the forceps in posterior positions of the occiput, if tlie head 
is well flexed before the instruments are applied, and if the 
blades are disengaged completely by unlocking them after 
each tractive effort, the occiput will be brought in contact 
with the pelvic floor first, and will thus rotate to the front 
without special difficulty. 



390 OBSTETRIC OPERATIONS. 

AVhen rotation forward of the occiput fails to take place 
plenty of time should be given for proper moulding of the 
head to occur. 

The normal mechanism of delivery in face to pubes cases 
must be borne in mind, and the forceps so used as to aid 
nature. The line of traction should be in the axis of the pel- 
vic cavity — that is, horizontally — until the forehead emerges 
sufficiently for the glabella to pivot under the pubic arch ; 
the handles are then raised so as to bring the occiput over the 
perineum, after which the face generally delivers itself by 
extension of the head. 

Once the glabella has pivoted many operators prefer to 
remove the blades and deliver the head manually. 

Forceps in Face Presentations. 

In posterior positions of the chin in face presentations the 
forceps are contraindicated. 

In mento-anterior positions, when nature's efforts are insuf- 
ficient to complete delivery, the forceps may be employed. 
The blades should be applied to the sides of the child's head 
in such a way as to secure a firm grasp of the occiput. Trac- 
tion should be made horizontally until the chin is brought 
under the pubic arch ; then by raising the handles and with- 
out pulling, the head is flexed, thus sweeping the face, vertex, 
and occiput successively over the perineum. This movement 
of flexion should be made with great deliberation, and when 
laceration of the perineum takes place and threatens to extend 
into the rectum a lateral incision should be made in order to 
avoid this troublesome complication. 

Forceps in Breech Cases. 

Indications : When in breech cases it is impossible to reach 
a foot or to employ a fillet or the finger to draw down the 
presenting part, the forceps may be used. When possible, 
the axis-traction forceps should be employed for this purpose. 

The grasp of the breech may be obtained by placing the 
tip of the blades over each trochanter and below the iliac 
crests. When this hold cannot be obtained, the blades may 



VERSIONS. 391 

be introduced so that one is in contact with the sacrum 
and one ilium of the child, while the other is in contact 
with the posterior surface of the opposite thigh, as recom- 
mended by Ollivier. 

The after-coming head has occasionally to be delivered by 
forceps after the failure of other methods. The application 
of the blades is not difficult, provided the child's body is 
held up over the abdomen of the mother by an assistant. 

The Dangers of Forceps Operations. 

The forceps judiciously and skilfully used should seldom 
result in the production of serious injury to either mother or 
child. 

When forceps operations are undertaken by unskilled 
operators and in unsuitable cases the most disastrous conse- 
quences may follow : the uterus has been perforated by the 
tips of the blades ; the cervix * and lower uterine segment 
have been torn away ; the pelvic joints have been sprung 
apart ; while most extensive vaginal lacerations are not in- 
frequent, as the result of improperly performed forceps 
operations. The most common injuries are : lacerations, more 
or less extensive, of the perineum and vagina, and certain in- 
juries of the child's head the result of compression of the 
blades. Contusions and abrasions of the face or scalp are not in- 
frequent, and occasionally facial paralysis may follow pressure 
upon facial nerve-trunks. Intracranial hemorrhages are not 
infrequent after forceps operations. Such hemorrhage may 
result in rapid death of the newborn child, or, if survived, 
may give rise to idiocy, hemiplegia, epilepsy, etc. Occasion- 
ally the cord may be around the child's neck, and be so ex- 
posed to pressure from the tip of the blades that fatal 
asphyxia may ensue. 

VERSIONS. 

Definition : The general term version is applied to such ob- 
stetric operations as are designed to bring about any altera- 
tion in the relation of the long axis of the child's head to the 
long axis of the uterus. 

Varieties : There are three varieties of versions : 



392 OBSTETRIC OPERATIONS. 

CcphallCj resulting in presentation of the head ; 

Pelvic, of the breech ; and 

Podalicj of one or both feet. 

Methods : There are three methods of performing version : 

External version, which is accomplished by manipulation 
through the abdomen ; 

Bipolar version, accomplished by external and internal 
manipulations combined ; 

Internal version, accomplished by the introduction of the 
hand within the uterus. 

External Version. 

By means of external version either the head or the breech 
can be made to present at the pelvic brim. It is probably 
the simplest and safest method of turning, as there is prac- 
tically no danger connected with it. 

The more practised the operator is in abdominal palpation 
of the pregnant uterus the more skilful will he prove in the 
performance of external version. 

Indications : The most common indication for external 
version is breech presentation, when diagnosed during the 
latter weeks of pregnancy. While the indications for this 
form of version are in general the same as those that apply 
to the other forms, the fact that it can be employed only be- 
fore or very early in labor limits its availability. 

Conditions for external version : The membranes should be 
intact or but recently ruptured. The uterine and abdominal 
walls should be lax and the child freely movable. These 
conditions are only present before the onset of labor or very 
early in its course, hence to these periods the operation is 
limited. 

Preparations : The bladder and rectum should be emptied. 
The patient should be in the dorsal decubitus, with her tliighs 
slightly flexed and the head and shoulders supported by pil- 
lows. The abdomen should be exposed or covered only by a 
sheet, under which the liands of the operator are placed. An 
anaesthetic is not required unless the patient is extremely 
nervous. 



VERSIONS. 393 



Method of Operation. 

The first duty of the operator is carefully to map out the 
position occu})ied by the child. This is done by palpation, 
supplemented by auscultation of the foetal heart. 

He should then plot out the manoeuvre he wishes to accom- 
plish from beginning to end, before attempting to displace in 
any way the foetus. 

In performing external version the most important point is 
to keep the foetal ovoid intact throughout the operation. 

The manoeuvres : The operator places a hand on each end 
of the foetal ovoid, with the palms facing and the fingers of 
one hand directed toward the wrist of the other. By the 
alternate flexion of the fingers of either hand the version is 
accomplished. One hand gives a movement of ascent and 
the other a movement of descent, each acting alternately. 

The extremity of the foetal ovoid it is desired to bring 
down is made to follow the shortest route which will bring it 
into proper relationship with the pelvic brim. Should uterine 
contraction occur during the manipulations, the operator must 
be content to hold the foetus in the position gained until re- 
laxation occurs, when the operation may be proceeded with. 

When the foetus has been placed in the desired position a 
vaginal examination should be made to ascertain whether the 
presenting part is properly over the inlet. 

To retain the foetus in position until the presenting part has 
engaged, longitudinal pads composed of folded towels, may be 
placed on either side of the foetus and a firm abdominal 
binder applied. 

Occasionally, when external version has been carried out 
after the onset of labor, it is advisable to rupture the mem- 
branes, so as to favor the retention of the foetus in its new 
position. 

Bipolar Version. 

The chief advantage of the bipolar method is that complete 
dilatation of the cervix is unnecessary, as by this method ver- 
sion can be accomplished as soon as tic o fingers can be inserted 
through the os uteri. 

Bipolar version has the disadvantage that it fails to give 



394 OBSTETRIC OPERATIONS. 

the operator such control of tlie foetus as is obtainable by the 
internal method. 

This form of version is also known as the Braxton-Hicks 
method. 

Indications : Placenta prcevia with but partial dilatation of 
the OS is given by most text-books as the chief indication for 
selection of this method of performing version. 

In the experience of the writer, the very fact that the pla- 
centa is situated in the lower uterine segment contraincUcates 
the employment of this method, as, with only two fingers 
through the os, the presenting part cannot be satisfactorily 
reached ; for the pelvic inlet is occupied more or less by the 
bulky placenta. For this reason in placenta prsevia, when 
version is desirable, the internal method should be selected 
and the os dilated until the whole hand can be introduced into 
the uterus. 

Other indications for this method are : abnormal presenta- 
tions or positions of the head, such as face or brow presenta- 
tions and prolapse of the cord, when diagnosed early in labor. 
It is also very useful in transverse cases, whether it is desired 
to bring down the breech or the head. 

Conditions for bipolar version : The membranes should be 
intact or so recently ruptured that the child is still freely 
movable. The cervix should admit two fingers, and the 
vagina be capable of containing the operator's hand if neces- 
sary. The uterine and abdominal walls should be lax. 

Preparation : The patient should be prepared as for a for- 
ceps operation. She should be placed in the dorsal position, 
across the bed, with her hips at the edge, the legs being sup- 
ported by chairs. The operator sits between tlie patient's 
thighs, after having well sterilized his hands and forearms. 
The external hand can be kept from contamination by wrap- 
ping it in a sterilized towel. 

Anaesthesia is desirable, but not necessary, provided the 
vagina and vulva are lax and the patient not nervous. 

Method of operation : Before proceeding to operate, the 
diagnosis of the position of the foetus should be confirmed by 
careful external and internal examination. The details of 
each movement of the operation should then be planned so 



VERSIONS. 395 

that the operator has clearly in mind exactly what he wishes 
to accomplish by his manoeuvres. 

In head presentations, in which it is desired to bring down 
the breech, the head should be moved in the direction in 
which the occiput points. 

The fingers of the hand, the palm of which points in the 
direction in which it is desired to move the presenting part, 
are then introduced through the cervix. Thus, if presentation 
is L. O. A. and it is desired to bring down the breech, two 
fingers of the left hand are introduced within the cervix, while 
the right hand presses down the breech, through the abdominal 
wall. The version is accomplished by a series of alternate 
pushes Avith either hand. Care should be taken not to rupture 
the membranes, should they be intact, until a foot or leg is 
within reach of the internal fingers at the pelvic brim. 

Iq correcting an abnormal presentation of the head by 
combined manipulation the fingers of the internal hand push 
the lowest part of the foetal head upward and backward while 
the external hand, having located the occiput through the ab- 
dominal wall, endeavors to force the vertex downward and 
forward within the pelvic brira. 

In such cases, if the membranes liave not ruptured, they 
should be broken as soon as the position of the head is altered. 
Pressure should tlien be maintained upon the fundus until the 
vertex has become firmly engaged in the brim. 

Internal Version. 

This method of version is most commonly employed, as it 
is probably the most rapid and effectual way of securing 
delivery when the head is not engaged in the pelvic brim. It 
is the most dangerous method of version, as the hand must be 
placed into the uterine cavity in order to seize one or both 
feet. 

Lidicatioiis : Eclampsia, placenta prsevia, threatened sud- 
den maternal death, prolapse of the cord, and accidental 
hemorrhage may be mentioned as indications for this method 
of version, especially when rapid delivery is desired. 

Other indications are transverse presentations, moderate 
pelvic contraction, prolapse of foetal members, and rupture 
of the uterus. 



396 OBSTETRIC OPERATIONS. 

Conditions for internal version : The cervix must be dilated, 
or dilatable ; the pelvis must be sufficiently ample to permit 
the passage of the after-coming head, and the uterus must not 
be tetanically contracted about the child. The condition of 
the lower uterine segment should be ascertained before version 
is attempted, and the position of the retraction-ring noted, if 
it be present. The foetus must not be impacted in the pelvis, 
but should be sufficiently movable to permit the presenting 
part to be pushed back. The child should be viable. 

Preparations : When possible the patient should be placed 
on a table for operation. Preparations should be made as for 
a forceps operation. The vagina should be scrubbed and 
rendered antiseptic, being afterward smeared with sterilized 
glycerin or oil. The most useful antiseptic for such cases is 
lysol or creolin, as these substances have lubricating qualities 
and render the employment of glycerin or oil unnecessary. 

It is Avell to have at hand some sterilized bandage-material 
or broad tape, in case it may be necessary to pass a noose 
about the foetal limbs, to facilitate extraction. The patient 
should be ancesthetized , and for this purpose chloroform is 
usually recommended as bringing about better uterine relaxa- 
tion than ether. It is desirable that the anaesthetic should be 
administered by a medical assistant. 

The patient should be placed in the lithotomy position with 
her hips at the edge of the bed or table. The operator, with 
his hands and arms sterilized and his clothing protected by an 
apron, sits or stands facing the patient. 

Method of operating : The first step in the operation is to 
confirm the diagnosis of the foetal position by a combined 
internal and external examination. The various steps of the 
operation of turning the foetus are then planned, and a deci- 
sion made as to which hand shall be introduced into the uterus 
and which foot of the infant seized. 

When the long axis of the foetus is in the long axis of the 
uterus, the operator should introduce the hand ichich corresponds 
to the side of the mother toward which the presenting part is 
directed. Thus in L. O. A. or L. O. P. positions the left hand 
is introduced into the uterus. In such cases the anterior foot 
should always be seized. In case of doubt both feet may be 
brought down. 



VEBSIONS. 397 

When the long axis of the foetus is transverse to the axis 
of the uterus the hand to be introduced is the one which corre- 
sponds to the side of the mother to ichich the breech is directed. 
AVhen the breech is directed to the mother's right side the 
operator should introduce his right hand. 

In dorso-auterior positions the near foot should be seized 
and brought down, and in dorsoposterior positions the remote 
foot. Thus when the child's back is directed to the front, 
seize the front (near) foot ; when the back is directed to the 
bach, seize the bach (remote) foot. 

Before introduction the hand and arm should be dipped in 
creolin solution or smeared with sterilized oil. 

The hand, with the tips of the fingers and thumb placed 
together so as to form a cone, is then introduced through the 
vagina and cervix with a rotary motion. The uterus should 
always be entered witli the palm of the hand directed toward 
the abdomen of the foetus. The hand should be pushed 
steadily though gently upward to the fundus, where the feet 
are usually to be found. A common mistake of inexperienced 
operators is to feel about for the feet before the hand has been 
introduced far enough. The foot can be easily recognized by 
the prominence of the heel and malleoli. 

The external hand, protected with a sterilized towel, should 
co-operate by making counter-pressure on the fundus, in order 
to steady the foetus as well as to press the breech down, so that 
the feet may more easily be reached. 

If the membranes be found intact, they should be ruptured. 
and the hand pushed quickly up, in order that the forearm 
may plug the vagina and so prevent escape of the liquor 
amnii. Should uterine contraction occur, the hand with the 
fingers extended should be held quiet until relaxation has 
taken place. 

If the shoidder be found impacted in the pelvis and an arm 
prolapsed, a noose of gauze bandage or tape should be slipped 
over the child's wrist, and then the impaction may be reduced 
by gentle upward pressure upon the body of the foetus. 

In reducing an impaction of the foetus the same rule ap- 
plies as in the reduction of an impacted hernia, ^' The part 
that has come down last should be returned first." Thus the 
upward pressure should first be applied to that portion of the 



398 OBSTETRIC OPERATIONS. 

fcietiis nearest the pelvic brim, and then successively along the 
body until the apex of the shoulder is reached. 

AVhen a secure grasp of the desired foot has been obtained 
it is drawn steadily down toward the pelvic outlet, the external 
hand at the same time being employed in directing the head 
toward the fundus. This turning movement should only be 
made when the uterus is entirely relaxed. 

The operation may be considered as complete when the child's 
breech is engaged in the pelvic inlet. When possible the case 
should then be left to nature to complete the delivery. 

After the completion of version the foetal heart should be 
auscultated and the general condition of the mother ascer- 
tained. Should either be at fault the case should be termi- 
nated by rapid extraction of the foetus. 

For details as to the various methods of extraction of the 
breech^ the reader is referred to the section on the Management 
of Breech Cases. 

The dangers of internal version are : laceration or rupture 
of the uterus from the employment of undue force, hemor- 
rhage, shock, and subsequent sepsis from uncleanliness at the 
time of operation. In order to prevent the latter the uter- 
ine cavity should be douched with a hot antiseptic solution 
(formalin, 1 : 500) as soon as the placenta has been delivered. 



SYMPHYSIOTOMY. 

Definition : Derived from aofxcpoacq, a joint, and rofrq, a 
cutting, symphysiotomy is the term applied to the operation 
of section of the symphysis pubis in a woman in labor. The 
object of the operation is to increase the diameter of a con- 
tracted pelvis, and thus to permit the delivery of a living 
child through the natural passages. 

History: The operation was first performed successfully by 
Sigault, in Paris, in 1777. It was comparatively popular dur- 
ing the early decades of the present century, but fell into dis- 
repute by 1858. 

In 1866 the operation was successfully revived by Morisani, 
of Naples, to whom is due the chief credit of the improved 
technique of the modern operation. It was reintroduced into 



SYMPHYSIOTOMY. 399 

Paris by Pinard in 1892, and was first performed in America 
by Jewett, on Sept. 30, 1892. 

Rationale of symphysiotomy : The separation of the sym- 
physis causes a lengthening of the diameters of the pelvis, the 
conjugate being the one affected most in consequence of the 
ends of the pubic bones moving dov/nward as well as outward 
when separated. The descent of the separated ends is due to 
the fact that each of the sacro-iliac joints rotates upon an 
oblique line running from above downward and from without 
inward. A separation of 3 cm. (li inches) causes a descent of 
2 cm. (jinch) ; still further descent being caused by the down- 
ward pressure of the foetal head. The separation of the 
pubic bones also permits the anterior parietal eminence of the 
foetal head to project into the interpubic space. 

Thus symphysiotomy results in enlargement of the pelvic 
canal by the separation and descent of the ends of the pubic 
bones, and by permitting a prominence of the foetal head to 
occupy the interpubic space. 

Indications : Symphysiotomy holds a place between Csesa- 
rean section and the minor operations of forceps and version. 
It is an operation designed to secure the birth of a living and 
viable child, and its chief rivals, in moderate degrees of pelvic 
narrowing, are the induction of premature labor and version 
or forceps at term. The following constitute the chief indica- 
tions for symphysiotomy : 

1. Simple flat pelves with a conjugata vera between 7 and 
9 cm. (2.6 and 3.1 inches). 

2. Generally contracted pelves, with a conjugata vera 
between 8.2 and 10 cm. (3.2 and 3.9 inches). 

3. Impacted or irreducible mentoposterior positions of the 
face. 

4. Impacted occipitoposterior positions of the vertex. 
Ankylosis or any diseased condition of the sacro-iliac joints, 

and the presence of infection contraindicate the operation. 

The time for operation is at the completion of the first stage 
of labor. 

Preparations : The instruments required for the operation 
are : a common scalpel, a slightly curved, blunt-pointed bis- 
toury, a Galbiati or a Faraboeuf knife, a metal female catheter, 
curved needles, needle-forceps, a few haemostatic forceps, an 



400 OBSTETRIC OPERATIONS. 

intra-uterine douche nozzle, and a pair of axis-traction 
forceps. 

The following materials should also be prepared : iodoform 
gauze strips, pledgets of absorbent cotton, sutures of catgut, 
silkworm-gut, and silk, iodoform and boric poAvder (1 : 8), a 
surgical dressing composed of iodoform gauze and absorbent 
cotton pads, all of which should be sterilized. Rubber adhe- 
sive plaster should be provided to keep the dressing in place, 
and also a binder of strong cotton, or, better still, of canvas, 
fastening with two or three broad strips of the same material 
provided with suitable buckles. 

The patient should be prepared as for an abdominal opera- 
tion, the pubic region shaved, and the vagina sterilized. A 
suitable table should be ready on which to place the patient 
during the operation. Three assistants are required, one to 
give the anaesthetic, and tAvo to support the patient's thighs 
and give what other help the operator may require. 

Sterile saline solution should be prepared in case of severe 
hemorrhage or shock, and other suitable restoratives should 
be handy. 

Preparations should also be made for the establishment of 
respiration should the child be born asphyxiated. 

The operation : There are two methods of performing sym- 
physiotomy, the Italian and the French. 

Italian method : The advantages of this method are that 
the wound is more readily kept from infection after delivery, 
and that the bladder and urethra are less liable to injury 
during the operation. 

The patient, having been anaesthetized, is placed in the 
dorsal position upon the table with her thighs somewhat 
flexed and supported by two assistants. The operator then 
notes the depth, direction, and thickness of the pubis, and 
locates the central depression on its upper margin which 
indicates the position of the symphysis. 

Standing on the right-hand side of the patient, the operator 
makes a vertical incision an inch long in the abdominal wall 
terminating at a })oint 1 cm. (f inch) below the upper 
margin of the symphysis. The incision should extend down 
to the superficial fascia. An assistant then inserts a metal 
catheter in the woman's urethra, holding it down and to one 



SYMPHYSIOTOMY. 401 

side so as to be clear of the symphysis. The attachments of 
the recti to the pubes are then cut sufficiently to permit the 
introduction of the forefinger. The forefinger of the left 
hand is then inserted into the wound and passed down behind 
the symphysis. Occasionally the foetal head may press so 
close to the pubes that tiie operator may find difficulty in 
inserting his finger behind the symphysis. In such cases the 
foetal head should be pushed up out of the way by an assist- 
ant with his fingers in the vagina. 

The retropubic tissues are separated by the index-finger, as 
it is pushed down behind the symphysis and hooked under 
the subpubic ligament. The curved blade of the Galbiati 
knife is then guided along the index-finger of the left hand 
into a position behind the joint, so that its top passes under 
the subpubic ligament. In place of the Galbiati knife an 
ordinary blunt-pointed, slightly curved bistoury may be 
used. 

The joint-structures are then divided with an upward, for- 
ward rocking movement of the knife. While the joint is 
being cut through, the sides of the pelvis should be supported 
by the assistants, in order to prevent the ends of the bones 
separating too much. Frequently one fails to cut the sub- 
pubic ligament in cutting through the joint, in which case it 
should immediately be severed by means of a blunt-pointed 
bistoury. 

Usually pretty severe hemorrhage follows the section of the 
joint, but firm packing of the wound with iodoform gauze 
invariably checks it. After the joint has been divided the 
catheter may be removed from the urethra. 

While occasionally a woman may be allowed to deliver 
herself after the symphysis has been divided, as a general 
rule it is better to terminate the labor at once hj forceps or 
version. 

During the delivery the assistants should exert firm lateral 
pressure upon the pelvis, to prevent too wide separation of 
the pubic bones ; the bones should not be allowed to separate 
more than 6.5 to 7 cm. (2.5 to 2.7 inches). 

After delivery has been completed the patient's thighs should 
be extended and her knees brought together. The operator, 
after having washed his hands, removes the gauze packing 

26— Ob?t. 



402 OBSTETRIC OPERATIONS. 

from the wound and passes his left index-finger behind the 
joint to make sure that the bladder has not been caught 
between the bones ; then having checked all hemorrhage, he 
sutures the wound with three or four deep silkworm-gut 
sutures. Most operators consider it unnecessary to attempt 
to suture the bones together ; one or two sutures, however, 
may be placed so as to include the fibrous tissue on the ante- 
rior surface of the joint. 

Vaginal and vulvar lacerations, if present, are then re- 
paired, and the bladder and urethra examined for possible 
injuries. The abdominal wall is then dressed with a strip of 
iodoform gauze and covered with layers of absorbent cotton. 
This dressing is held in place by means of one or two broad 
strips of rubber adhesive plaster which pass well behind the 
wings of the pelvis on either side. 

A firm cotton binder is then applied, or a broad canvas 
belt which can be fastened by means of straps and buckles. 
The patient is then removed to a bed with a firm level mat- 
tress, such as would be used for a fracture case. It is ad- 
vantageous to support the sides of the pelvis with sand bags 
reaching from the knees to above the waist. The patient's 
knees should be tied together. 

French method : The chief advantage of this method is that 
on account of the long incision the operator can see what he 
is doing at each step. 

The operation : An incision three inches long is made begin- 
ming on the abdominal wall one and one-half inches above 
the symphysis and extending downward to the clitoris. The 
edges of the wound are separated by retractors and the exact 
location of the symphysis determined. 

By careful dissection first the lower and then the upper 
margins of the symphysis are exposed. An index-finger is 
then inserted behind the joint so as to detach the retropubic 
tissues. A broad, flat, grooved director is then guided along 
the index-finger behind the joint, either from above down- 
ward or from below upward. The joint is then cut from 
without inward by means of a Farabauif knife. During de- 
livery the wound is packed with iodoform gauze to prevent 
possible infection. 

After delivery the wound is sutured with strong silkworm- 



SYMPHYSIOTOMY. 403 

gut, the sutures being so passed as to include the firm fibrous 
outer covering of the ends of the bones. 

After-treatment : The after-care of a symphysiotomy case 
is usually very troublesome, the difficulties being to keep the 
wound from infection and to prevent separation of the ends of 
the pubic bones. There is usually very considerable oedema 
of the vulva present for several days after the operation. 

Special attention should be paid to the toilet of the vulva. 
Generally the catheter must be used for several days each 
time it is desired to empty the bladder. A strong assistant 
should be at hand to support and lift the pelvis, ^vhile a nurse 
slips the bed-pan under the buttocks. The knees should be 
kept tied together for two weeks and the patient kept flat on 
her back for three or four weeks. The sutures may be re- 
moved on the sixth to the tenth day. 

Should it be necessary to disinfect the parturient canal 
during the piierperium, the patient's legs should be raised 
straight in the air without bending the knees and supported 
by an assistant. In this Avay whatever treatment may be 
required can be carried out without causing the patient 
much inconvenience. 

The ])atient may be allowed to sit up in from three to four 
weeks after the operation, but should not be allowed to w^alk 
about much before the sixth week. 

Dangers of symphysiotomy: In Italy 54 symphysiotomies 
have been performed, with but 2 maternal deaths. In 
America the mortality is 12 per cent. Under favorable con- 
ditions and at the hands of skilled operators the maternal 
death-rate should be almost nil. 

Failure of the separated pubic bones to unite may leave the 
woman with some looseness in the joint, and cripple her pow- 
ers of locomotion. The sacro-ih'ac joints may be damaged by 
too wide a separation of the pubic bones. Troublesome 
hemorrhage frequently takes place, but can usually be con- 
trolled by pressure and haemostatic suture. Vesical and 
urethral injuries have been reported. The anterior vaginal 
wall is liable to laceration during extraction of the child. 

In the opinion of the writer, the chief drau'hach of sym- 
physiotomy is the great dislocation of the internal organs 
which accompanies forcible extraction. Xot infrequently 



404 OBSTETRIC OPERATIONS, 

these cases suffer later from prolapsus uteri, on account of the 
lax condition of the structures of the pelvic outlet which 
remains after the operation on account of the pubic bones 
being separated ; the whole mechanism of labor is interfered 
with, so that the head descends through the pelvis in a trans- 
verse position, the occiput failing to rotate to the front. More 
or less damage to the pelvic fascia results and fails to undergo 
proper repair, so that the woman later develops cystocele, 
rectocele, or even a prolapsus uteri. 

Failure to carry out rigid aseptic precautions after opera- 
tion may lead to infection of the wound with serious con- 
sequences. 

CESAREAN SECTION. 

Definition : Csesarean section may be defined as an obstetric 
operation for the delivery of a mature foetus by means of an 
incision through the abdominal and uterine walls. 

History : The operation dates from prehistoric times. The 
first recorded operation was performed by a butcher in Swit- 
zerland, in 1500. Until the development of antiseptic surgery 
the operation was attended by enormous fatality, and was 
only performed as a last resort. The uterine incision was 
formerly left unsutured, as it was supposed that sutures would 
not hold on account of uterine contractions. 

Sanger, of Leipsic, has done probably more than anyone 
else to perfect the modern operation. In 1882 he showed 
that the uterine incision could be sutured with safety provided 
the suture-material employed was sterile. Since that time the 
mortality attending the operation has been steadily reduced. 
Under favorable circumstances and at the hands of skilful 
operators the maternal mortality is about 5 per cent. ; but 
in general practice the mortality, according to Harris, ranges 
from 30 to 40 per cent. 

The indications for this operation may be absolute or relative : 

An absolute indication is the presence of some condition 
which renders impossible any other method of delivery — e. g. 
— extreme degrees of pelvic contraction (conjugate under 6.5 
cm.) ; marked pelvic deformity resulting from osteomalacia, 
kyphosis, and spondylolisthesis ; foreign growths obstructing 



CESAREAN SECTION. 405 

the pelvic canal ; cicatricial contraction of the vagina ; and 
carcinoma of the cervix or of the rectum. 

A relative indication is the presence of some condition 
which makes doubtful the delivery of a living child by the 
natural passages. In some cases the question to be decided 
is whether Csesarean section or one of the alternative opera- 
tions (symphysiotomy, forceps, version, craniotomy) will 
secure the best results. The individual peculiarities of each 
case as it arises must be studied before a decision can be made. 
In general, after consultation with a confrere^ the physician 
should leave the decision to the woman or her husband, 
having explained to them the nature of the case. 

The commonest relative indications are : a conjugate of 
6 to 8 cm. (2J to 3J inches) ; and tumors which cause but a 
moderate degree of pelvic obstruction (Fig. 117). 

The best time for operation, when this is elective, is within 
a week of the expected date of labor. 

Preparations for Csesarean Section. 

The patient, if possible, should be under observation for 
some days before the operation is undertaken. During this 
period the urine should be examined, the diet restricted, and 
the bowels carefully regulated. General tonics, especially 
strychnine, should be given daily, if there be any indication. 

The evening before the operation the patient should be 
given a full dose of castor oil, or half an ounce of Epsom 
salt in a tumblerful of water. The abdomen and pubes 
should be shaved and scrubbed with a soft brush, tincture of 
green soap, and hot water. After being thoroughly rubbed 
with alcohol the abdomen is to be covered with sterile gauze 
and a binder applied. 

If the patient is nervous and unable to sleep, sulphonal 
(gr. x-xv) may be given in warm broth or milk. The fol- 
lowing morning the patient may be given a cupful of broth 
two hours before the operation. If the bowels have not been 
freely moved, an enema of turpentine and soapsuds (3J to Oj) 
may be given. 

Before the patient is placed on the operating-table she 
should be catheterized and the abdomen, vulva, and vagina 



406 OBSTETRIC OPERATIONS. 

finally sterilized. The vagina is then lightly packed with 
iodoform gauze. 

After the patient is placed on the operating- table the chest 
and thighs are covered with blankets protected by sterilized 
towels, and a large piece of sterilized gauze composed of four 
thicknesses is arranged so as to cover the whole body from 
chest to knees. 

The usual dressings and accessories for an abdominal opera- 
tion should be provided in addition to the following instru- 
ments : 

2 scalpels, 

1 pair of ordinary scissors. 

1 dozen artery-forceps, 

1 pair of retractors, 

Curved and straight needles, 

1 needle-holder. 

A large thin-walled rubber tube as a uterine ligature, 

Silk, silkworm-gut, and catgut for sutures and ligatures. 

Four assistants are required — one to give the anaesthetic, 
one to compress the cervix and control hemorrhage, one to 
receive and attend to the child, and one to assist the operator 
throughout the operation. 

The Caesarean Operation. 

The operator first cuts a slit in the gauze extending from 
the pubes to a short distance above the umbilicus. 

An incision is then made in the linea alba extending from 
a point 4 cm. (1 J inches) above the pubes to a point the same 
distance below the umbilicus. The peritoneal cavity is then 
opened with the usual precautions. Such an incision is 
sufficient for the introduction of the hand and the withdrawal 
of the child. Many operators prefer, however, to extend the 
abdominal incision to a point above the umbilicus, and to 
turn the uterus out of the cavity before incising it. 

The advantages claimed for this latter method are : a saving 
of time, better control of the uterus, and that it is easier to 
prevent the entrance of fluids into the general peritoneal 
cavity. Its disadvantages are : the great length of the ab- 
dominal incision, which predisposes to hernia later ; and the 



CESAREAN SECTION. 407 

greater extent of adhesions occurring later between the ab- 
dominal wall and the uterus. For these reasons the shorter 
incision is generally to be preferred. 

Having exposed the uterus to view, the operator then passes 
a piece of rubber tubing over the fundus and down to the 
lower segment, so that it will encircle the uterus below the 
presenting part of the child ; the ends are given to an assist- 
ant, who, by exercising traction, compresses the uterus and 
steadies it against the symphysis, thus controlling hemorrliage. 

An incision is then made into the uterus extending from the 
fundus to just above the retraction-ring. This incision must 
be made quickly and boldly in spite of the severe hemorrhage 
whicii occurs. 

Extraction of child: The operator then plunges his hand 
into the cavity of the uterus, pushing to one side the placenta 
if it be encountered, seizes the child by a foot, and extracts it 
as rapidly as possible. While the uterine incision is being 
made the assistant should press the abdominal wall to the 
sides of the uterus, to prevent the entrance of fluids into the 
peritoneal cavity. As soon as the child is extracted the 
uterus usually contracts. When the child is withdrawn from 
the uterus it is given to an assistant to hold, while the opera- 
tor clamps the cord in two places with artery-forceps and cuts 
between them. 

The placenta is then grasped on its foetal surface and 
loosened from its attachment by simply squeezing it. The 
membranes peel off from the uterine wall as the placenta is 
withdrawn through the incision. 

Should the uterus fail to contract properly, it may be 
stimulated by the application of hot cloths and friction. 

It is then lifted out of the abdominal cavity and a large 
piece of gauze slipped under it, to hold it and also to prevent 
the intestines protruding. 

After some iodoform powder has been dusted into the 
cavity the uterine wound is closed by means of silk sutures. 
These sutures are placed at intervals of about 1.5 cm., or 
about half an inch, and should include only the muscular coat. 
The peritoneal edges are then approximated by a second 
layer of interrupted silk sutures, placed at shorter intervals 
than the first layer. After the sutures have been tied there 



408 OBSTETRIC OPERATIONS. 

slioLild be no hemorrhage either from the wound or from the 
needle-punctures. When tlie uterine wound has been sutured 
the elastic ligature around the cervix may be withdrawn. 

Closure of abdominal wound : The abdominal cavity should 
then be sponged dry with cheesecloth sponges, particular 
attention being paid to the renal fossse. 

Having returned the uterus to the abdominal cavity and 
placed it in proper position, the omentum is then to be brought 
down and carried behind instead of in front of it, in order to 
avoid omental adhesions. 

The abdominal incision is then closed in the usual manner 
and a surgical dressing applied. The vaginal gauze is then 
removed and a vulvar pad applied. 

After-treatment: The after-treatment should be much the 
same as after any abdominal operation. During the first 
twenty-four hours it may be necessary to give a hypodermic 
injection of morphine for the relief of pain. The child may 
be put to the breast after twenty-four hours have elapsed. 

Special attention should be given to the care of the vulva, 
in order to prevent infection of the vagina. 

The abdominal sutures may be removed from the tenth to 
the fourteenth day, and the patient may be allowed out of bed 
at the end of three Aveeks. An abdominal support should be 
worn for six months after the operation. 

Porro Operation. 

In 1876 Porro suggested that the ordinary Csesarean opera- 
tion should be supplemented by the amputation of the uterus 
along with the tubes and ovaries. 

After amputation of the uterus, two methods of treating the 
stump are available. 

By the extraperitoneal method the stump is transfixed by 
long needles and retained in the lower angle of the wound. 

By the intraperitoneal method the stump is sewed over in 
such a manner as to cover it completely with peritoneum, 
after which it is dropped into the abdominal cavity. 

The advantages of the Porro operation are that it renders 
subsequent uterine hemorrhage or conception impossible, and 
decreases the risk of puerperal infection, while it adds nothing 
to the danger of the operation. 



SELECTION OF OBSTETRIC OPERATIONS. 409 

IndicatioHs : Coeliohystercctomy, or Porro-Csesarean section, 
is indicated when labor has been prolonged and manipulations 
have been attempted to secure delivery, but have failed and 
sepsis is probable ; when the uterus or its appendages are so 
diseased as to require a subsequent operation for their removal ; 
and when any condition is present which will make it impos- 
sible for a child to be delivered subsequently by the natural 
passages. 

The preparations are the same as for Csesarean section, 
except that the following instruments should be added to the 
list given previously : 1 large pedicle-scissors ; 4 curved 
large pedicle-clamps ; 2 large volsellum forceps ; 2 right and 2 
left aneurism-needles ; and 1 right and 1 left sharp-pointed 
pedicle-needles. 

Operation : The abdominal incision should extend from two 
inches above the umbilicus to just above the symphysis. The 
uterus is draw^n up out of the abdomen, and a sterile towel is 
packed into the peritoneal cavity to prevent the escape of the 
intestines. The assistant then draws the edges of the abdomi- 
nal incision close about the cervix, which he grasps firmly 
with both hands so as to control hemorrhage when the uterine 
incision is made. 

The uterus is then incised and the child and placenta 
removed as quickly as possible. The ovarian arteries are 
then sought and tied, as also the arteries of the round liga- 
ments. The broad ligaments are then clamped and cut; 
peritoneal flaps for covering over the stump are then pre- 
pared, the uterus amputated, and the uterine arteries tied. 

The stump is then oversewn and dropped, the peritoneal 
cavity is washed out, and the abdominal wall closed. 

GENERAL RULES GOVERNING THE SELECTION OF OB- 
STETRIC OPERATIONS IN CASES OF OBSTRUCTED 
LABOR. 

Conjugate of 9.5 cm. or less : The best method is to induce 
labor at or about four weeks before the expected termination 
of pregnancy. If the condition of the pelvis is only discov- 
ered after labor has begun, the labor may be allowed to go on 
for twenty-four hours. Attention should be paid to the 



410 OBSTETRIC OPERATIONS. 

woman's general condition and the distention of the lower 
uterine segment. The choice of operation then lies between 
forceps, version, symphysiotomy, and Csesarean section. 

Forceps may be applied and the patient placed in the 
Walcher position ; if after twenty minutes the head does not 
become engaged, they should be discarded. Version may suc- 
ceed where the forceps have failed, but the risk for the child 
is considerable. If the danger of version is considered too 
great to risk, then symphysiotomy should be done. If after 
the pubis has been divided the head descends to the brim, the 
delivery may be completed by forceps. Should the head 
remain high after separation of the pubes, then version offers 
a more favorable result to the child. 

The most important conditions affecting the choice of opera- 
tion are the size and compressibility of the foetal head. A 
compressible head may pass through a pelvis that would prove 
an insuperable obstacle to an incompressible head of the same 
size. 

The relative size of the head and pelvis may be approxi- 
mately determined, by grasping the head firmly with the ex- 
tended fingers placed on the abdominal wall, and pressing it 
down upon the pelvic brim for some time. The pressure 
thus exerted should be in the axis of the pelvic inlet. If the 
head can thus be forced within the brim, the natural forces 
will certainly secure the engagement. 

Conjugate of 7 cm. or less : If at the thirty-sixth week the 
head can be forced into the brim by steady pressure from 
above, labor should be induced. The risk to the child of in- 
ducing labor before the thirty-sixth week is too great to afford 
much chance of its surviving its birth. If at this time the 
head is too large to engage, the case should be left till about 
term and Csesarean section performed. Embryotomy should 
never be performed upon a living child if it possibly can be 
avoided. (3n the other hand, Csesarean section should not 
be rashly undertaken by an operator unskilled and inex- 
perienced in abdominal surgery. As before said, the final 
decision should be left to the patient or her nearest rela- 
tions. 

When the pelvic canal is obstructed by a tumor which can- 
not be dislodged or which would be subjected to dangerous 



EMBRYOTOMY. 411 

pressure during the passage of the child, the safest method 
of delivery would be Csesarean section or the Porro operation. 

EMBRYOTOMY. 

Definition : Embryotomy is a generic term which includes 
all the destructive operations by which the volume of the 
foetus is reduced to permit of its extraction through the natu- 
ral passages. The term thus includes craniotomy, decapita- 
tion, evisceration, and amputation of the extremities. 

Indications : Embryotomy should never be performed on a 
living child when any other obstetric operation offers a reason- 
able chance of saving its life. 

The patient and her friends may decline any conservative 
operation and insist on embryotomy. In such case, if the 
physician is of opinion that a conservative operation would 
offer a reasonable chance of saving the child, he is at liberty 
to transfer the case to some one else should he so desire. 
When such a course is not open to him, the physician must 
under protest yield to the desire of the patient and her friends, 
as he has no legal right to compel them to follow his judg- 
ment. 

Provided the foetus is dead, the following conditions may 
be mentioned as constituting the ordinary indications for 
embryotomy : 

1. Deformity of the pelvis where forceps or version is 
impossible, or would expose the mother to unnecessary risk. 

2. Obstruction of the parturient canal by tumors — uterine, 
ovarian, malignant, or osseous. 

3. Impaction of the presenting part : face presentations, 
occipitoposterior positions, locked twins. 

4. Eclampsia, or other causes demanding rapid delivery 
where forceps or version would be difficult or prolonged. 

5. Monstrosities ; hydrocephalus ; the latter constitutes an 
indication for embryotomy on the living child, for if the 
condition is so marked as to prevent delivery there is no 
probability of the child surviving should conservative opera- 
tion be performed. 

Embryotomy-instruments : The object of embryotomy being 
to reduce the bulk of the foetus, the presenting part has first 



412 



OBSTETRIC OPERATIONS, 



to be perforated and its contents evacuated. If this proced- 
ure fails to reduce the bulk of the foetus sufficiently, it is 




Smellie's scissors. 



necessary then to crush the presenting part by means of a 
powerful instrument, so that delivery may be accomplished. 
Perforators : The best instruments for perforating the head 



Fig. 144. 




Blot's perforator. 



are Smellie^s scissors and Blot's perforator (Figs. 143 and 144), 
though a pair of scissors with a long handle answers the pur- 



FiG. 145. 




Braun's cranioclast. 



pose admirably. The Germans prefer to perforate the skull 
by means of a trephine with a long handle. 

Cranioclast : This is a powerful instrument for seizing the 



EMBRYOTOMY. 



413 



Fig. 14G. 



head after it has been perforated (Fig. 1 45). It consists of 
two blades, one for insertion inside and the other outside the 
skull. At the ends of the handles there is a powerful com- 
pression screw which enables the operator to obtain a firm 
grip of the head. 

Cephalotribe : This instrument is simply a heavy forceps 
specially modified for compressing the head after it has been 
perforated (Fig. 146). The blades are applied on either side 
of the head, which is then crushed by 
tightening a screw attached to the ends 
of the handles. 

The most perfect instrument for reduc- 
ing the bulk of the foetal head is Tar- 
nier's basiotribe, which is at once a per- 
forator, a cranioclast, and a cephalotribe 
(Fig. 147). This instrument is composed 
of a perforator, two heavy fenestrated 
blades of unequal length, and is provided 
with a pow^erful compression screw. 

Method of use : After disarticulating 
the instrument the perforator is pushed 
through a suture or fontanelle, the short 
blade is then applied on the outside of 
the head like an ordinary forceps blade, 
and is then articulated with the perfora- 
tor, when the compression screw is tight- 
ened until the blade is forced close to the 
perforator, thus crushing one side of the 
head. 

After loosening the compression screw 
the long blade is applied to the opposite 
side of the head and its handle articu- 
lated to the handle of the short blade, 
when the screw is again tightened, thus 
completely crushing the head. Thus the 
base as well as the vault of the skull can 
be crushed and flattened to a little less 
than two inches (Fig. 148). 

Hook and crotchet : This instrument consists of a curved 
metal bar terminating at one end in a blunt hook, at the other 




Lusk's cephalotribe. 



414 



OBSTETRIC OPERATIONS. 



in a crotchet tip (Fig. 149). The crotchet-tip end may be in- 
serted into the skull after perforation and hooked into the 
foramen magnum, thus permitting the instrument to be used 



Fig. 148. 




Tarnier's basiotribe. 



Basiotripsy accomplished. 



as an extractor. The hook may be used to pull down the 
neck. 

Braun^s hook, which consists of a steel rod with a strong 
transverse handle at one end and a sharply bent hook, tipped 



EMBRYOTOMY. 415 

with a rounded button, at the other, is employed as a decapi- 
tator. 

Zweifel has devised a decapitator which consists practically 
of two Braun's hooks so arranged that by separating the 
handles the tips can be moved in opposite directions. 

In America, where extreme degrees of pelvic contraction 
are rarely to be met with, embryotomy can usually be carried 
out with comparatively little risk to the mother, provided the 
operator is careful and moderately skilful, by means of a pair 
of blunt-pointed scissors with short blades and a long handle ; 
and an old-fashioned hook and crotchet. The writer has per- 
formed seven embryotomies with these two instruments, and 

Fig. 149. 



Crotchet. 

in no case was there laceration or injury of the maternal soft 
parts, and the mothers all made uneventful recoveries. 

The time for operation is at the conclusion of the first stage 
of labor. 

Preparations : The patient after being anaesthetized is placed 
in the lithotomy position with her hips at the edge of the bed 
or table on which she lies. The vulva, vagina, and inner 
surfaces of her thighs are then scrubbed with spirits of green 
soap and hot water, to be followed with a douche of formalin 
or bichloride solution. The bladder is then catheterized. The 
douche-bag should be filled Avith sterile water and hung in a 
position to secure a good, forceful stream. 

The instruments to be used in the operation are then placed 
in a convenient position after being sterilized. 

Operation. 

The operator, suitably prepared, first makes a careful inter- 
nal examination, to ascertain the exact conditions present. If 
possible, the hand should be passed into the uterus till the 
cord can be reached, to make certain the foetus has perished. 
When the head is found presenting at the brim it should be 
steadied from above by an assistant when possible. 



416 OBSTETRIC OPERATIONS. 

The perforator: The operator then locates the suture or 
fontanelle with the tips of the index and middle fingers of his 
left hand placed in the vagina. The perforator held in his 
right hand is then guided into position between the fingers of 
the left hand placed on the head. The head is perforated 
bv steady upward pressure of the instrument held in the right 
hand. Having penetrated the skull, the perforator is swept in 
every direction to break up the brain, and the opening is 
enlarged in every direction. The douc^he nozzle is in- 
serted into the opening in the skull, and, a return flow 
having been provided for, a stream of water is let into the 
cavity to wash away the broken-up brain-substance. 

If a cranioclast or cephalotribe is at hand, it should now be 
applied and the head carefully extracted, care being taken to 
guard the sharp edges of the cranial bones from cutting the 
maternal tissues. 

When the crotchet hook is used, it is to be thrust into the 
skull and hooked into the base about the forearm magnum. 
After obtaining a firui hold the head is drawn down. 

When long scissors are employed to open the skull-cavity 
the tips of the blades should be kept between the two fingers 
of the operator's left hand which are in contact with the 
head. The cutting is done by little snips, separating the 
blades as little as possible. Having cut through to the skull, 
the tip of the scissors with the blades closed is thrust through 
a fontanelle or suture. The blades are then separated as 
widely as possible and swept about to break up the brain- 
substance. The cerebral cavity is washed out and the crotchet 
used as described. 

Sometimes after the cranial contents have been removed 
the child is expelled by natural efforts. 

In most cases in which the pelvis will permit of their proper 
application, the ordinary forceps may be used as extractors of 
the perforated head. 

Perforation of the after-coming head : When it is necessary 
to perforate the after-coming head, the perforator may be in- 
serted through the quadrilateral fontanelle behind the ear, 
or into the foramen magnum through the mouth of the child. 

Decapitation: In impacted shoulder presentation it may be 



EMBRYOTOMY, 417 

necessary to sever the head from the trunk in order to effect 
delivery. 

This may be performed by passing the hook end of the 
hook and crotchet over the neck to draw it down as far as 
possible, where it is held by an assistant. By means of a 
pair of long-handled scissors the operator can then cut through 
the neck, being careful to guard the blades between the two 
fingers of the left hand held in the vagina. 

Evisceration : This is rarely indicated. When necessary it 
may be done with a pair of long-handled scissors. 

In all cases after the separation of the placenta, the uterine 
cavity should be douched with hot salt solution. Lacerations 
of the soft tissues should then be sought, and if found sutured 
at once. 

Dangers of embryotomy : The chief dangers of embryotomy 
ai*e, lacerations of the maternal tissues by spicules of bone or 
by instruments ; and sepsis. 

As the mother has been exhausted by prolonged and in- 
effectual efforts to complete labor, before embryotomy is 
performed, she has but little resisting power should septic 
infection take place ; while the bruised and lacerated condi- 
tion of the soft parts favors the development of sepsis. 

27— Obst. 



INDEX. 



Abortion, 194 
complete, 198 
definition, 194 
diagnosis, 197 
etiology, 196 
origin, foetal, 197 
maternal, 196 
paternal, 196 
frequency, 195 

induction of (see Induction of abor- 
tion), 371 
inevitable, 197 
missed, 201 
labor, 201 
partial, 198 
patliologT. 196 
blood-mole, 196 
cast-off decidua, 196 
effusion of blood, 196 
prognosis, 198 
symptoms, 195 
' expulsion of the ovum, 195 
hemorrhage, 195 
pain, 195 
threatened, 197 
treatment, 198 
active, 200 
after-, 201 
expectant, 199 
of inevitable, 199 
prophylactic, 199 
of threatened, 199 
tubal, 203 
Accidental hemorrhage, 263 
apparent, 263 
concealed, 263 
etiology, 264 
symptoms, 264 
treatment, 265 
Albuminuria in pregnancy, 181 
Alimentary system, changes of, in 

pregnancv, 43 
Allantois, 30 



Amnion, 29, 35 
liquor amnii, 35 
function, 35 
pathology, 156 
dropsy, 156 
hydramnios, 156 
oligohydramnios, 156 
premature rupture, 159 
sac, 30 
Amniotic bands, 158 
Anasarca of foetus, 166 
Anatomy, obstetric (see Obstetric anat- 
omy), 56-96 
Apoplexy of placenta, 162 
Area pellucida, 28 
Areolae, abscess of, 331 
Arrest of lactation, 331 
indications, 331 
method, 331 
Atresia of vagina, 302 
Axis of bony outlet, 76 
of brim, 76 
parturient, 76 
of plane of the vulvovaginal ring, 

76 
relation of uterine to foetal, 90 



B. 

Ballottement, 50 
Bladder, calculus, 303 
cystocele, 303 
distended, 303 
Blastodermic vesicle, 26 
Blood-mole, 196 
Bloodvessels in pregnancy, 184 
Breasts, abscess {see Mammary abscess), 
329 
absence, 320 

changes in pregnancy, 41 
diseases of, 172 
abscess, 172 

eczema of the nipples, 172 
excessive secretion, 172 
engorgement of, 322 

419 



420 



INDEX. 



Breasts, engorgement of, treatment, 
322 

breast-bandage, 324 

breast-pump, 322 

massage, 323 

Murphy binder, 324 

nursing, 322 
hypertrophy, 320 
inflammation of (see Mastitis), 326 
mastitis (see Mastitis), 326 
supernumerary, 320 



Csesarean section, 404 
history, 404 
indications, 404 
operation, 406 
Porro, 408 
Calculus of bladder, 303 
Caput succedaneum, 115 
Carcinoma of cervix, 303 
Cardiac diseases in pregnancy, 184 
Cerebral hemorrhage in puerperium, 

338 
Cervical lacerations, repair, 370 

operation, 370 
Cervix, atresia, 298 
carcinoma, 303 
cicatricial contraction, 298 
impaction of anterior lip, 299 
polypi, 305 
rigidity, 298 

treatment, 298 
softening of, 41, 46 
violet discoloration, 41, 47 
Chorion, 30, 31, 34 

hydatidiform degeneration, 159 
pathologv, 159 
villi, 31, 32 
Circulatory system, changes of, in 

pregnancy, 43 
Climacteric, 18 
Ccelum, 29 
Colostrum, 149 
Conception, 21 

Constipation in pregnancy, 174 
Cord (see Umbilical cord), 30, 34 
Corpus luteum, 20 

of pregnancy, 20 
Cough in pregnancy, 183 
Cutaneous system, changes of, in 

pregnancy, 44 
Cystitis in puerperium, 336 
Cystocele, 303 



I>. 



Decidua, 23, 34 



Decidua, cells, 25 
coalescence, 23 
development of, 23 
layers, 23 
pathology, 154 
atrophy, 156 

decidual endometritis, 154, 155 
acute, 154 
etiology, 154 
treatment, 154 
chronic, 155 
catarrhal, 155 
diflTuse, 155 
occurrence, 155 
treatment, 155 
reflexa, 23 
serotina, 23 
vera, 23 
Dental caries in pregnancy, 173 
Development, 23 

decidua (see Decidua), 23 
foetus (see Foetus), 25 
placenta (see Placenta), 3 
Diagnosis of pregnancy, 45-51 
Diarrhoea in pregnancy, 174 
Diphtheria in puerperium, 333 
Ductus arteriosus, 38 

venosus, 36 
Dyspnoea in pregnancy, 183 
Dystocia, 209 

due to abnormalities of the foetal 
appendages, 253 
accidental hemorrhage, 

263 
adherent placenta, 266 
coiling of cord about 

neck, 258 
placenta prsevia (see Pla- 
centa prxvia), 258 
prolapse of cord, 254 
retained placenta, 266 
short cord, 253 
anomalies of foetal development, 
248 
encephalocele, 252 
hydrencephalus, 252 
hydrocephalus, 250 
meningocele, 252 
monstrosities, 253 
overgrowth of foetus, 248 
premature ossification of 

skull, 249 
tumors of foetal trunk, 
252 
malpositions of the foetus, 209 
breech presentations, 221- 

237 
brow pi-esentations, 221 



INDEX. 



421 



Dystocia, due to malpositions of the 
foetus, face presentations, 
215-221 
occipitoposterior cases, 209- 

214 
plural births, 245 
prolapse of the foetal limbs, 

244 
transverse presentations, 

237-244 
triplets, 248 
twin labors, 245 
maternal, 268-312 
anomalies in forces of labor, 268- 
272 
of tlie maternal soft structures 
(see Uterus, Vagina, etc.), 297- 
312 
of the pelvis (see Pelvis), 272- 
297 

E. 

Eclampsia, 188 
course, 190 
definition, 188 
diagnosis, 192 
eclamptic fit, 189 
duration, 189 
etiology, 190 

toxaemia, 190 
frequency, 188 
pathological anatomy, 191 
kiduevs, 191 
liver, \92 
lungs, 192 
spleen, 192 
prognosis, 192 
symptoms, 188 

premonitory, 188 
termination, 190 
treatment, 192 

during attack, 193 
medical, 193 
obstetrical, 194 
prophylactic, 192 
urine, 188 
Ectoderm, 28 
Ectopic gestation, 202 
definition, 202 
diagnosis, 206 
etiology, 204 
frequency, 202 
pathology, 204 
primary, 202 
secondary, 202 

tubal, infundibular, 202 
interstitial, 202 



Ectopic gestation, secondary tubal, 
true, 202 
tubo-ovariau, 202 
symptoms, 205 
terminations, 202,203 
treatment, 207 
varieties, 202 
abdominal, 202 
ovarian, 202 
tubal, 202 
Eczema of nipples, 172 
Elephantiasis of foetus, 165 
Embryology, 21 
Embryonic area, 28 
Embryotomy, 411 
dangers of, 417 
definition, 411 
evisceration, 417 
indications, 411 
instruments, 411 
basiotribe, 413 

blunt-pointed scissors, 415, 416 
Braun's hook, 414 
cephalotribe, 413, 416 
cranioclast, 412, 416 
hook and crotchet, 413, 416 
perforators, 412, 416 
operation, 415 
perforation of after-coming head, 
416 
Encephalocele, 252 
Endocervicitis, 172 
Endometritis, decidual, acute, 154 
chronic, 155 
in puerperal septic infection, 347, 350 
Entoderm, 28 
Epiblast, 26, 28 
permanent, 28 
primitive, 28 
Episiotomy, 361 
advantage of, 362 
definition, 361 
indications, 361 
operation, 362 
Erysipelas in puerperium, 333 
Erythema in nuerperium, 333 
Eutocia, 96, 209 

F. 

Fibromyoma of uterus, 304 
Foetal circulation, 36 

head, flexion of. 85, 108, 109 

moulding of. 86 
heart-sounds, 132 
movements, 96 
trunk, 88 
diameters, 88 



422 



INDEX. 



Foetal trunk, mobility, 88, 89 
FcEtus, anasarca, 166 
anomalies, 165 
centre of gravity, 96 
circulation (see Feetal circulation), 36 
contagious diseases, 168 
death of, 168 

causes, 168 

sequelae, 169 
development, 25 
elephantiasis, 165 
head of, 77 

base, 77 

diameters, 82-84 

flexion of, 85 

glabella, 81 

mobility of, 88, 89 

moulding of, 86 

occiput, 81 

planes, 85 

circumferences, 85 

protuberances, 81 
frontal, 82 
occipital, 81 

sinciput, 81 

vault, 77 
fontanelles, 78 

false, 80 
sutures, 78 

vertex, 80 
ichthyosis, 166 
mature, 76 
monstrosities, 165 
mortality of, 165 
ossification of skull, 249 
overgrowth, 248 

treatment, 249 
positions (see Positions), 93 
posture, 89 

normal, 89 
presentations (see Presentations), 91 
rachitis, 166 

shape relative to uterus, 96 
syphilis, 167 

diagnosis, 167 

infection, 167 

manifestations, 167 

treatment, 168 
tuberculosis, 168 
tumors of trunk, 252 
Fontanelles. 78 

false, 80 
Forceps, axis-traction, 377 
description, 375 
operation, 374 

in breech cases, 390 

dangers of, 391 

in dorsal position, 381 



Forceps operation in dorsal position, 
axis-traction, 377, 383 
with ordinary forceps, 386 
distention of perineum, 383 
extraction, 382 
introduction of blades, 381 
support of limbs, 381 
in face presentations, 390 
high, 376, 381 
history, 374 
indications for, 378 
in left lateral position, extraction, 
388 
insertion of blades, 386 
low, 376, 381 
medium, 381 
methods, 380 
Continental, 380 
English, 380 
in occipitoposterior cases, 389 
posture of patient, 380 
preparations for, 379 
Funic souffle, 133 

G. 

Galactocele, 331 
Galactorrhoea, 322 
Gingivitis in pregnancy, 173 
Graafian follicle, 18 

membrana granulosa, 18 

number, 18 

ovum (see Ovum), 18, 19 

tunica fibrosa, 18 
propria, 18 

H. 

Hsematoma of vagina, 302 
Hsematuria in pregnancy, 180 

in puerperium, 337 
Heart murmurs in pregnancy, 184 
Hegar's sign, 48 

Hemorrhage, accidental (see Accidental 
hemorrhage), 263 
haematoma, 317 
post-partum, 312 
definition, 312 
diagnosis, 313 
etiology, 312 
symptoms, 313 
treatment, 314-316 
puerperal, 317 
secondary, 315 
Hemorrhoids in pregnancy, 180 

in puerperium, 335 
Hernia into umbilical cord, 165 
Herpes in pregnancy, 187 



INDEX. 



423 



Hydramnios, 156 

diaguosis, 157 

etiology, 156 

symptoms, 157 

treatment, 158 
Hydrocephalus, 250, 252 
Hvmeu, unruptured, 302 
Hypoblast, 26, 28 

cleavage, 28 

permanent, 29 



Ichthyosis of foetus, 166 
Icterus in pregnancy, 179 
Impetigo in pregnancy, 187 
Impregnation, 21 
Indigestion in pregnancy, 174 
Induction of abortion, 371 
definition, 371 
indications, 371 
methods, 372 

dilatation and curetting, 372 
drugs, 372 
of premature labor, 373 
indications, 373 
methods, 374 
Krause's, 374 
Tarnier's, 374 
Infectious diseases in pregnancy, 187 
Insanity in puerperium, 338-341 
Inversion of uterus, 310-312 

K. 

Kidney of pregnancy, 181 



Labor, delayed, 270 
causes, 270 
diagnosis, 270 
treatment, 271 
missed, 201 

normal (see Normal labor), 96 
pathology (see Dystocia), 209-212 
precipitate, 268 
etiology, 268 
treatment, 269 
premature, induction of (see Induc- 
tion of premature labor). 373 
Lacerations of cervix (see Cervical 
lacerations). 370 
of perineum ''see Perineal lacerations), 
362 
Lactation, 148 
arrest of (see Arrest of lactation) , 331 
colostrum (see Colostrum), 149 



Lactation, establishment of, 150, 151 

mammarv glands, 149 

milk (see Milk), 149 
Leucorrhcea of vagina, 169 
Liquor amnii, alterations in character, 

159 
Lochia, 146 

alba, 146 

character, 146 

composition, 146 

odor, 146 

quantity, 146 

rubra, 146 

serosa, 146 

M. 

Malaria in puerperium, 334 
Mammae (see Breasts), 320 
Mammary abscess, 329 
of areolae, 331 
location, 329 
symptoms, 329 
treatment, 329 
incision, 330 
Mastitis, 326 
etiology, 327 
symptoms, 327 
treatment, 328 
abortive, 328 
varieties, 326 
glandular, 326 
parenchymatous, 326 
post-mammary, 326 
subcutaneous, 326 
Measles in puerperium, 332 
Membranes, 29 
rupture of, 136 
at term, 33 
Meningocele, 252 
Menopause, 18 
Menstruation, 17, 20 
cause, 17 
cessation, 18 
character of flow, 17 
duration, 18 
onset, 17 

and ovulation, 20 
quantity, 18 
structural changes, 17 
suppression, 45 
Mesoblast, 29 
cleavage, 29 
Mesoderm, 29 
Milk, 149 

chemical composition, 149 
quality, 150 
quantity, 150 



424 



INDEX. 



Milk, secretion of, 150 
deficient, 320 
excessive, 321 
galactorrhoea, 322 
polygalactia, 321 
Miscarriage (see Abortion), 194, 195, 

201 
Mole, blood-, 196 
fleshy, 155, 196 
tubal, 203 
vesicular, 159 
symptoms, 159 
treatment, 161 
Monstrosities, 253 
Multipara, 97 
Myelitis in puerperium, 337 

N. 

Nephritis in pregnancy, 182 
Nervous system, changes of, in preg- 
nancy, 43 
Neuralgia in pregnancy, 185 
Neuritis in puerperium, 337 
Neuroses in pregnancy, 185, 186 
Nipples, anomalies, 320 
inversion, 320 
sore, 325 

treatment, 325 
supernumerary, 320 
Normal labor, 96 

anaesthetics, use of, 126, 127 
antisepsis, 119 
agents, 120 
nurse, 122 
obstetrician, 121 
patient, 123 
blood lost in, 118 
duration, 97 
first stage, 102 

anatomy of soft parts, 107 
clinical phenomena, 106 
initial labor-pains, 106 
reflex vomiting, 107 
dry labors, 105 
management, 128 
examination, 129 
auscultation, 132 
palpation, 129 
vaginal, 134 
preliminary conduct of phy- 
sician, 128 
succeeding the examina- 
tion, 136 
mechanism, 103 

action of uterine fibres, 104 
dilatation of cervix, 103 
hydrostatic pressure, 103 



Normal labor, first stage, os uteri, 106 
rupture of membranes, 105 
signs and symptoms, 102, 103 
characteristic, 103 
premonitory, 102 
forces of, 99 
contractions of abdominal mus- 
cles, 101 
of uterus, 99 
duration, 99 
efiiect of, 100 
intermittent, 99 
involuntary, 99 
painful, 99 
peristaltic, 99 
of vaginal and pelvic mus- 
cles, 99, 101 
gravity, 102 
polarity, 100 
retraction of uterus, 100 
management of, 119 
onset, causes of, 97, 98 
preparation for, 124 
nurse, 126 
patient, 125 

labor-room, 125 
physician, 124 
obstetric bag, 124 
second stage, 107 
anatomy, 115 
clinical phenomena, 113 

moulding of head, 114 
management, 137 

laceration of perineum, 138 
perineal stage, 137 
position, 137 
rapid cases, 137 
mechanism, 107 
delivery of trunk, 113 
head movements, 108 
descent, 108 
extension, 112 
external rotation, 112 
flexion, 108, 109 
internal rotation, 110 
restitution, 112 . 
stages, 97 
third stage, 116 

management, 141 

Crede's method of expres- 
sion, 141 
final measures, 142 
lacei-ations, 141 
retraction of uterus, 142 
mechanism, 116 
expulsion of placenta, 117 
separation of placenta, 116 
of membranes, 117 



INDEX. 



425 



O. 

Obstetric anatomy, 56-96 
operations, 361-417 
Caesarean section, 404-409 
embryotomy, 411-417 
episiotomv, 361 
forceps, 374-391 
general rules governing selection 

of, 409-411 
induction of abortion, 371 
of premature labor, 373 
repair of cervical lacerations, 370 
complete tear, 368 
external superficial tear, 363 
internal tear, 364 
vaginal and perineal lacera- 
tions, 362 
symphysiotomy, 398-404 
versions, 391-398 
(Edema of placenta, 164 
of vagina, 169 
of vulva, 169 
Oligohydramnois, 156 
Ovarian cysts, 306 
Ovulation, 18, 20 

and menstruation, 20 
Ovum, 18, 19 
at different periods of pregnancy, 

35, 36 
discus proligerus, 18 
fertilization, 22 
germinal spot, 19 

vesicle, 19 
immature, 19 
impregnated, 25 
maturity, 19 
nucleolus, 19, 26 
nucleus, 19, 25 
polar bodies, 19 
pronucleus, 19, 26 
segmentation, 26 
yolk, 19, 25 
zona pellucida, 19 



Parametritis in puerperal septic in- 
fection, 350 

Parotitis in pregnancy, 173 

Parturient axis, 76 

Parturition, 57 

Pathology of amnion (see Amnion), 156 
of breasts (sec Breasts), 172 
of chorion (see Chorion), 159 
of decidua (see Decidua), 154 
of foetus (see Foetus), 165 
of placenta (see Placenta), 161 
of pregnancy, 154 



Pathology of the pregnant woman, 
169 
abortion (see Abortion), 194 
albuminuria, 181 
bloodvessels, 184 
cardiac diseases, 184 
constipation, 174 
cough, 183 
dental caries, 173 
diarrhoea, 174 
dyspncea, 183 

eclampsia (see Eclampsia), 188 
ectopic gestation (see Ectopic 

gestation), 202 
gingivitis, 173 
hsematuria, 180 
heart murmurs, 184 
hemorrhoids, 180 
herpes, 187 
icterus, 179 
impetigo, 187 
indigestion, 174 
infectious diseases, 187 
kidney of pregnancy, 181 
nephritis, 182 
acute, 182 
chronic, 182 

differential diagnosis, 182 
treatment, 182 
neuralgia, 185 
neuroses, 185, 186 
parotitis, 173 
phthisis pulmonalis, 183 
pigmentation, 187 
pneumonia, 183 
premature labor (see Premature 

labor), 194 
ptyalism, 173 
salivation, 173 
scanty urine, 180 
thyroid gland, 185 
toxaemia (see Toxsemia), 188 
vomiting, 174 

pernicious (see Pernicious vom- 
iting), 175 
simple, 175 
of umbilical cord (see Umbilical 

cord), 164 
of uterus (see Uterus), 170 
of vagina (see Vagina), 169 
of vulva (see Vulva), 169 
Pelvic canal, soft parts, 71-76 
muscles, 71-74 
floor, 72 
fascia, 74 
measurement, 72 
muscles, 71-74 
segments, 72 



426 



INDEX. 



Pelvic floor, segments, pubio, 72 

sacral, 72 
Pelvi-genital canal, 57, 61 
Pelvimetry, 275 
measurements, 275-279 
external, 275 
internal, 277 
Pelvis, 61 
anomalies of, 272-297 
classification, 273 
deep, 282 
diagnosis, 274 

due to injuries, tumors, or dis- 
ease, 294 
spinal curvature, 296 
kyphoscoliosis, 297 
kyphosis, 296 
lordosis, 296 
scoliosis, 297 
flat, 283 

mechanism of labor, 287 
non-rachitic, 283 
rachitic, 285 
treatment of labor, 288 
frequency, 272 
funnel-shaped, 282 
justomajor, 279 
justominor, 279 
malacosteon, 291 
masculine, 282 
obliquely contracted, 289 
pseudomalacosteon, 292 
shallow, 282 

spondylolisthetic pelves, 293 
transversely contracted, 291 
diameters, 67-70 
of the brim, 67-70 
conjugate, 68 
measurements, 70 
oblique, 70 
transverse, 70 
false, 63 
inclination, 71 
joints of, 62 

mobility, 63 
lateral grooves, 65, 66 
planes, 66 
the brim, 66 
the cavity, 67 
the outlet, 67 
true, 63 
cavity, 64 

boundaries, 64-66 
inferior strait, 64 
inlet, 63 
outlet, 64 
superior strait, 63 
Perineal body, 75 



Perineal lacerations, complete tear, 
368 
conditions, 368 
operation, 368-370 
external tear, 363 
internal tear, 364 
conditions, 364 
method of repair, 365-368 
repair, 362 
Perineum, 75 

rigidity, 302 
Peritonitis in puerperal septic infec- 
tion, 351 
Pernicious vomiting, 175 
duration, 175 
etiology, 176 
physiological uterine contrac- 
tions, 176 
predisposing causes, 176 
symptoms, 175 
treatment, 178 
dietetic, 178 

digital dilatation of cervix, 179 
drugs, 179 
hygienic, 178 
induction of abortion, 179 
rectal alimentation, 178 
Phlegmasia alba dolens, 351 
Phthisis pulmonalis in pregnancy, 183 
Pigmentation in pregnancy, 50, 187 
Placenta, 31 
adherent, 164, 266 
causes, 267 
treatment, 268 
anomalies, 161 
of position, 161 
of shape, 161 
of size, 161 
of weight, 161 
apoplexy, 162 
causes, 163 
definition, 162 
forms, 162 
results, 163 
symptoms, 163 
treatment, 163 
aspects, 33 
battledore, 161 
circular sinus, 34 
cotyledons, 33 
degeneration, calcareous, 162 

fatty, 162 
functions, 34 
horse-shoe, 161 

inflammation (see Placentitis), 163 
intervillous spaces, 32 
maternal blood, 33 
membranacea, 161 



INDEX. 



427 



Placenta, oedema of, 164 
polypi, 196 
praevia, 258 
centralis, 258 
etiology, 259 
lateralis, 258 
margiualis, 258 
symptoms, 260 
treatment, 261 
premature separation of (see Acci- 
dental hemorrhage), 263 
retained, 266 
sinuses, 32 
site, 34 
structure, 31 
succenturiata, 161 
sypliilis of, 164 
at term, 33 
tumors of, 164 
white infarctions, 162 
Placentitis, 163 

pathological changes, 163 
Plural births, 245 
Pneumonia in pregnancy, 183 

in puerperium, 333 
Polygalactia, 321 
Polypi of cervix, 305 

of placenta, 196 
Porro operation, 408 
Position, 92 
Positions, 93-96 
breech, 95 
face, 94 

occipitoposterior, 209 
diagnosis, 209 
management of labor, 212 
at the pelvic inlet, 213 
in the pelvic cavity, 214 
mechanism, 210 
abnormal, 211 
prognosis, 214 
somatic, 95 
vertex, 94 
Pregnancy, ballottement, 50 
changes in alimentary system, 43 
circulatory system, 43 
cutaneous system, 44 
maternal organism, 38 

uterus, 38 
nervous system. 43 
respiratory system, 43 
urinary system, 44 
corpus luteum of, 20 
diagnosis, 45-51 
differential, 52, 53 
of life or death of child, 54 
of nulliparity, 53 
of parity, 53 



Pregnancy, diagnosis, summary of, 51 
trimesters, 45-51 
first, 45-48 

objective signs, 46 
Hegar's sign, 48 
softening of cervix, 46 
violet discoloration, 47 
symptoms, 45 
mammary changes, 46 
nausea, 46 

suppression of menstrua- 
tion, 45 
vomiting, 46 
second, 48 

objective signs, 49 
symptoms, 48 
third, 50 
objective signs, 51 
symptoms, 50 
duration, 44 

common rule, 44 
date of quickening, 45 
table, 45 
foetal heart-sounds, 49 

movements, 49, 51 
Hegar's sign, 48 
hygiene of, 54-56 
likely to occur, 22 
linese albicantes, 44, 51 
management of, 54-56 
normal, 21 

pathology of (see Pathology of preg- 
nancy), 154 
pigmentation, 42, 44, 50 
pressure-symptoms, 51 
quickening, 49 
"settling," 51 
uterine contractions, 49 

souffle, 49 
vomiting of, 43 
Premature labor (see Abortion), 194, 

201 
Presentation, 90 
I Presentations, 91 
! breech, 221 
causes, 222 
diagnosis, 223 
frequency, 222 
management, 226 

arms delivered, head retained, 

234 
arrest at brim, 228 
delivery of after-coming head, 

233 
impaction in pelvis, 230 
rapid extraction of trunk, 230 
mechanism, 224 
abnormal, 225 



428 



INDEX. 



Presentations, cephalic, 91, 92, 96 
face, 95, 215 
causes, 215 
diagnosis, 215 
management, 219 
mechanism, 217 
occurrence, 215 
positions, 215 
pelvic. 91, 93 
shoulder, 95 
somatic, 91, 93 
transverse, 92, 237 
causes, 237 
diagnosis, 238 
frequency, 237 
mechanism, 239 

spontaneous evolution, 240 

version, 239 
with body doubled up, 240 
positions, 237 

dorso-anterior, 237 
dorsoposterior, 237 
Primigravida, 97 
Primipara, 97 
Primitive groove, 28 

streak, 28 
Prolapse of cord, 254 
of foetal limbs, 244, 245 
of uterus, 172, 300 
Pruritus of vagina, 169 

of vulva, 1H9 
Ptyalism, 173 

in pregnancy, 173 
Puerperal period (see Puerperal state), 
143 
pathology of (see Uterus, Breasts, 
Hemorrhage), 312 
state, 143 

anatomy of parts, 143 
bladder, 144 
broad ligaments, 144 
peritoneum, 144 
uterus, 143 
vagina, 144 
vulva, 144 
beginning, 143 
duration, 143 
management of, 150 
after-pains, 153 
care of breasts, 151 
of genitalia, 151 
contraindications to suckling, 

152 
lying-in room, 150 
nourishment, 152 
rest, 152 
physiological phenomena, 143 
physiology of, 145 



Puerperal state, physiology of, invo- 
lution, 145 

abdominal walls, 147 

circulatory system, 147 

digestive apparatus, 148 

lactation (see Lactation), 148 

ovaries, 147 

pelvic joints, 147 

skin, 148 

tubes, 147 

urinary system, 147 

uterus, 145 
lochia (see Lochia), 146 
mucosa, 146 
muscle-cells, 145 
vessels and nerves, 145 

vagina, 147 

vulva, 147 
septic infection, 345-361 
bacteriology, 345 

cervix, 346 

saprsemia, 346 

vagina, 346 
definition, 345 
diagnosis, 354 

culture from uterus, 355 

lochia, 354 
frequency, 345 
pathology, 347 

auto-infection, 352 

endometritis, 347 

modes of infection, 351 

parametritis, 350 

peritonitis, 351 

phlegmasia alba dolens, 351 

pyaemia, 351 

salpingitis, 350 

ulcer, 347 

vaginitis, 347 
symptomatology, 352 

onset, 352 

parametritis, 353 

peritonitis, 353 

pyaemia, 353 

septicaemia, 354 
treatment, 357 

general, 359 

serum-therapy, 360 

local, 357 

prophylaxis, 357 
Puerperiura (see Puerperal state), 143 
fever other than septic, 343, 344 
intercurrent diseases, 332-361 
anaemia, 334 

cerebral hemorrhage, 338 
cystitis, 336 
diphtheria, 333 
erysipelas, 333 



INDEX. 



429 



Puerperium, intercurrent diseases, 
erythema, 333 

hsematuria, 337 

hemorrhoids, 335 

incontinence of urine, 336 

insanity, 338-341 

malaria, 334 

muscles, 332 

myelitis, 337 

neuritis, 337 

pneumonia, 333 

pyelonephritis, 336 

retention of urine, 335 

rheumatism, 333 

rotheln, 333 

scarlet fever, 332 
septic infection (see Puerperal septic 

infection), 345 
sudden death, 341 

entrance of air into uterine si- 
nuses, 343 

pulmonary embolism, 341 

thrombosis, 341 
Pyaemia in puerperal septic infection. 

351 
Pyelonephritis in puerperium, 336 



Q. 

Quickening of pregnancy, 49 



Eachitis of foetus, 166 

Eespiratory system, changes of, in 

pregnancy, 43 
Eetroversion of uterus, 170 
Eheumatism in puerperium, 333 
Eotheln in puerperium, 333 
Eupture of uterus, 306 



Salivation, 173 

Salpingitis in puerperal septic infec- 
tion, 350 
Scarlet fever in puerperium, 332 
Segmentation, 26 

morula stage, 26 
Semen, 21 
Somatopleure, 29 
Spermatozoids, 21 

meeting-place with ovum, 22 
Splanchnopleure, 29 
Subinvolution, 318 
Symphysiotomy, 398 

dangers of, 403 



Symphysiotomy, definition, 398 

French method, 402 

history, 398 

indications, 399 

Italian method, 400 

rationale, 399 
Syphilis of fcBtus, 167 

of placenta, 164 



Thyroid gland in pregnancy, 185 
Toxaemia (see Eclampsia), 188 
Treatment of abortion, 198 

of accidental hemorrhage, 265 

of adherent placenta, 268 

of apoplexy of placenta, 163 

of decidual endometritis, acute, 154 
chronic, 155 

of delayed labor, 271 

of eclampsia, 192 

of ectopic gestation, 207 

of engorgement of breasts, 322 

of mammary abscess, 329 

of mastitis, 328 

of nephritis in pregnancy, 182 

of overgrowth of foetus, 249 

of pernicious vomiting, 178 

of post-partum hemorrhage, 314-316 

of precipitate labor, 269 

of prolapse of umbilical cord, 255 

of puerperal septic infection, 357 

of retroversion of uterus, 171 

of rigidity of cervix, 298 

of rupture of uterus, 309 

of sore nipples, 325 

of subinvolution of uterus, 319 

of syphilis of foetus, 168 

of vesicular mole, 161 
Triplets, 248 
Tubal mole, 203 
Tuberculosis of foetus, 168 
Tumors of placenta, 164 

of uterus, 172, 304-306 
Twin labors, 245 

complications, 247 

u. 

Ulcer in puerperal septic infection, 

347 
Umbilical cord, 30, 34 
anomalies, 164 
coils, 164 
knots, 165 
of length, 164 
coiling about foetal neck, 258 
hernia into, 165 



■6/^ 



430 



INDEX. 



Umbilical cord, prolapse of, 254 
diagnosis, 255 
treatment, 255 
short, 253 
vein, 36 
Uracil us, 30 

Urinary system, changes of, in preg- 
nancy, 44 
Urine, incontinence of, in puerperium, 
336 
retention of, in puerperium, 335 
scanty, in pregnancy, 180 
Uterine bruit, 133 
contractions in pregnancy, 49 
inertia, 270 

souffle of pregnancy, 49 
Uterus, arteries of, 39 
cavity of, 57 

changes from pregnancy, 38 
contractions, 40, 99 
dextro-rotation, 41 

diagnosis, 171 
displacements of, 299-302 
double, 297 
endocervicitis, 172 
fibromyoma, 304 
full-term, relation to contiguous 

structures, 60 
inversion, 310-312 
ligaments, 59 
lymphatics, 39 
muscle-fibres, 39, 57 

layers of, 57-59 
nerves, 40 
peritoneum, 60 
prolapse, 172, 300 

relation to pelvis and abdomen, 
fourth month, 40 
ninth month, 40 
seventh montb, 40 
sixth month, 40 
third month, 40 
retroversion, 170 

anatomical results, 170 
causation, 170 
treatment, 171 
mild cases, 171 
severe cases, 171 
rupture of, 306 
etiologv, 306 
site, 307 
symptoms, 308 
treatment, 309 
segments of, 59, 100 
lower, 59 
upper, 59 



Uterus, septate, 297 
subinvolution, 318 

diagnosis, 319 

etiology, 318 

treatment, 319 
tumors, 172, 304-306 
walls of, 57 

V. 

Vagina, atresia, 302 
hsematoma, 302 

lacerations of (see Perineal lacera- 
tions), 362 
leucorrhcea, 169 
oedema, 169 
pruritus, 169 
septa, 302 
varices, 469 

violet discoloration, 41, 47 
Vaginitis in puerperal septic infec- 
tion, 347 
Varices of vagina, 169 

of vulva, 169 
Vegetations of vulva, 170 
Version, spontaneous, 239 
Versions, 391 
definition, 391 
methods, 392 
bipolar, 393 
indications, 394 
method, 394 
external, 392 
indications, 392 
method, 393 
internal, 395 
indications, 395 
method, 396 
varieties, 391 
cephalic, '392 
pelvic, 392 
podalic, 392 
Vesicular mole, 159 
Vitellus, 25 

Vomiting of pregnancy, 43, 46, 174, 175 
Vulva, oedema, 169 
pruritus, 169 
varices, 169 
vegetations, 170 

w. 

Wharton's jelly, 34 



Yolk-sac, 30 



;.hbD?9 



LIBRARY OF CONGRESS 



022 216 015 7 









